A  MANUAL 


PATHOLOGICAL  ANATOMY. 


B7 


CARL  ROKITANSKY,  M.D., 

CUBATOB  OF  THE  IMPEBIAL  PATHOLOGICAL  MUSEUM,  AND  PBOFESSOE  AT  JI 
tJMVEKSITY  OF  VIENNA,  ETC. 


TRANSLATED   FROM   THE    LAST   GERMAN   EDITION 
BY 

WILLIAM  EDWARD  SWAINE,  M.D.,        CHARLES  HEWITT  MOORE, 
EDWARD  SIEVEKING,  M.D.,  GEORGE  E.  DAY,  M.D.,  F.R.S. 


FOUR  VOLUMES   IN   TWO. 
VOLS.  I.  II. 


PHILADELPHIA: 
BLANCHAED    &    LEA.     , 

1855. 


C.    SHERMAN    &    SON,    PRINTERS, 

19  St.  James  Street. 


A   MANUAL 


PATHOLOGICAL  ANATOMY. 


BY 


CARL  ROKITANSKY,  M.D., 

THE  IMPERIAL  PATHOLOGICAL  MUSEUM,  AND  PROFESSOB  AT  THE 
CMYEKSITY  OF  VIENNA,  ETC. 


VOLUME  I. 
GENERAL  PATHOLOGICAL  ANATOMY. 

TRANSLATED   FROM   THE   GERMAN, 

BY 

WILLIAM  EDWAKD   SWAINE,   M.D., 

FELLOW   OF  TEE  ROYAL  COLLEGE  OF  PHYSICIANS; 
PHYSICIAN   EXTRAORDINARY  TO   H.   R.   H.  THE   DUCHESS   OF   KENT. 


PHILADELPHIA: 

BLANCHARD    &    LEA. 
1855. 


\  10 


BIOLOGY 

LID"    -' 


AMERICAN  PUBLISHER'S  NOTICE. 


THE  numerous  unsuccessful  attempts  which  have  been  made  to 
present  the  following  work  in  an  English  translation,  sufficiently 
attest  the  very  general  estimation  in  which  it  is  held,  as  well  as  the 
difficulty  of  the  undertaking.  The  task  having  at  last  been  executed 
by  the  united  labors  of  four  gentlemen,  each  well  qualified  for  the 
portion  intrusted  to  him,  the  American  publishers  take  much  plea- 
sure in  presenting  to  the  profession  of  the  United  States,  this  great 
store-house  of  pathological  knowledge,  in  a  convenient  and  accessible 
form.  The  world-wide  reputation  of  the  author  and  of  his  work 
render  eulogy  superfluous,  while  the  appearance  of  the  translation 
under  the  auspices  of  the  Sydenham  Society  is  a  guarantee  of  its 
fidelity.  Under  these  circumstances,  and  as  subsequent  papers 
and  researches  of  the  author  have  been  introduced  in  their  appro- 
priate places  by  the  translators,  it  has  not  appeared  to  the  publishers 
that  additions  were  necessary  or  desirable  to  such  a  work  or  to  such 
an  author,  and  they  have  consequently  endeavored  simply  to  secure 
an  accurate  reprint.  For  greater  convenience  of  reading  and  refer- 
ence, and  to  lessen  the  cost,  the  four  volumes  have  been  bound  in 
two,  the  paging,  titles,  &c.,  rendering  each  complete  in  itself. 

The  volumes  of  the  English  Edition  were  not  published  in  their 
regular  sequence,  Volume  n.  being  issued  first,  and  Volume  I.  last. 
The  reader  is  therefore  referred  to  Dr.  Sieveking's  Preface  to  Volume 
n.,  as  well  as  to  Dr.  Swaine's  Preface  to  Volume  L,  for  some  expla- 
nation of  the  work,  and  of  the  manner  and  auspices  under  which  it 
has  appeared. 

PHILADELPHIA.  August,  1855. 


EDITOR'S  PREFACE 

TO    VOL.    I. 


IN  issuing  this  portion  of  Rokitansky's  "  Pathological  Anatomy," 
it  is  necessary  to  offer,  on  behalf  of  the  Council  of  the  Sydenham 
Society,  some  apology  for  the  delay  which  has  attended  the  com- 
pletion of  this  important  and  voluminous  work.  In  his  interest- 
ing preface  to  the  second  volume,  Dr.  Sieveking  has  recorded 
one  reason  for  the  order  in  which  the  volumes  have  been  pub- 
lished; but  he  has  not  adverted  to  the  main  consideration  by  which 
the  Council  was  influenced,  namely,  the  apparently  well-founded 
hope  that  they  might  be  enabled  to'  present  the  Association  with 
the  histological  portion  of  the  work  in  a  new  and  revised  edition. 
Encouraged  from  time  to  time  in  this  hope  by  the  author  him- 
self, the  Council  did  not  hesitate  to  defer,  from  year  to  year,  the 
publication  of  the  first  volume,  until  they  felt  that  it  would  be 
improper  to  tax  the  patience  of  the  members  any  further.  The 
new  edition  is  still  promised,  but  with  no  surer  pledge  for  its 
early  completion  than  heretofore!  The  editor  has,  however, 
availed  himself  to  a  considerable  extent  of  certain  papers  read  by 
the  author  before  the  Imperial  Academy  of  Sciences  at  Vienna ; 
namely,  On  the  Structure  and  Growth  of  Cyst  and  of  Cancers, 
&c.  He  has  even  found  it  not  at  all  incompatible  with  the  gene- 
ral unity  and  concordance  of  the  work  to  substitute,  almost  bodily, 
the  author's  more  recent  essay  on  "  Cyst  and  Alveolus,"  for  the 
comparatively  brief  and  imperfect  article  on  the  same  subject  in 
the  original.  These  papers,  there  is  reason  to  believe,  contain  the 
principal  results  of  the  author's  more  recent  investigations,  and 
therefore,  in  all  probability,  the  most  important  of  the  additions 
that  might  be  anticipated  in  a  new  edition.  The  Council  has 
also  sanctioned  the  introduction  of  two  plates  in  illustration  of 
the  newly  added  matter. 

At  the  conclusion  of  the  work  will  be  found  a  copious  Index  to 
the  four  volumes  collectively.  To  this  each  editor  has  contributed 
his  respective  share,  thus  offering  to  the  English  reader  facilities 
altogether  wanting  in  the  original  work. 


viii  EDITOR'S    PREFACE. 

On  the  other  hand  the  editor  has  felt  the  necessity  of  abridging 
somewhat  the  author's  general  introduction,  partly  because,  totally 
unlike  the  general  tendency  of  the  work,  it  is  of  too  "  transcen- 
dental" a  character  either  to  suit  the  English  language  or  to  har- 
monize with  English  ideas;  but  more  particularly  because  it  is 
interwoven  with  a  train  of  speculative  reasoning  upon  the  relation 
between  power  and  matter,  which  might,  in  this  country,  very 
possibly  give  rise  to  misinterpretation  and  rebuke. 

"What  Dr.  Sieveking  justly  alleges  of  the  general  peculiarities  of 
Rokitansky's  style,  and  of  the  difficulty  of  rendering  his  writings 
intelligible  in  English,  is,  by  all  who  are  conversant  with  the  origi- 
nal, admitted  to  apply  with  especial  force  to  the  first  volume.  Upon 
this  ground  the  editor  ventures  to  urge  his  claim  for  a  fair  measure 
of  indulgence  on  the  reader's  part. 

In  conclusion,  the  editor,  having  been  disappointed  of  a  promised 
autobiographical  sketch,  takes  leave  to  subjoin  a  few  extracts  from 
a  short  account  of  the  career  of  this  great  pathologist,  copied  by  a 
friendly  hand  from  the  last  edition  [1854]  of  Brockhaus's  "  Conver- 
sations Lexicon."  ^ 

"  Charles  Rokitansky,  the  •  founder  of  the  German  [it  should 
rather  have  been  called  Austrian]  medico-anatomical  school,  was 
born  at  Konigsgraetz,  in  Bohemia,  was  educated  at  the  Gymnasium  of 
Leitneritz,  and  graduated,  at  Vienna,  in  1828.  Shortly  afterwards  he 
was  appointed  Assistant  in  the  pathologico-anatomical  department 
of  the  University,  and,  in  1834,  Professor  of  Pathological  Anatomy. 
At  the  same  time  he  was  instituted  Prosector  at  the  General  [united 
Civil  and  Military]  Hospital  at  Vienna,  and  also  sole  medico-legal 
Anatomist  for  the  examination  of  all  doubtful  cases  of  death  through- 
out that  metropolis. 

"  The  immense  fund  of  materials  thus  placed  at  his  disposal  [the 
number  of  corpses  dissected  by  him  is  summed  up  at  30,000]  was 
almost  entirely  reserved  for  the  elaboration  of  that  grand  work 
on  pathological  anatomy,  which,  in  the  consciousness  of  having 
thoroughly  mastered  the  subject,  he  gave  to  the  world  between  the 
years  1842  and  1846 ;  which  has  passed,  unaltered,  through  three 
reimpressions ;  and  which,  under  the  auspices  of  the  Sydenham 
Society,  has  been  translated  into  the  English  language." 

"  In  1849,  Eokitansky  was  appointed  Dean  of  the  Medical  Faculty, 
and,  in  1850,  Eector  of  the  University,  of  Vienna." 

YORK,  January,  1855. 


AUTHOR'S  PEEFACE. 


THE  appearance  of  this  first  volume  brings  the  publication  of  my 
"  Pathological  Anatomy"  to  a  close.  As  was  the  case  with  the  earlier 
volumes,  the  completion  of  this  one  has  been  delayed  by  lack  of 
leisure,  and  especially  by  long  and  repeated  attacks  of  illness. 

Whilst  engaged  in  working  out  the  design  of  this  Pathological 
Anatomy,  I  have  throughout  endeavored  to  act  the  part  of  a  clinical 
teacher;  and  I  believe  that,  in  so  doing,  I  have  apprehended  the 
requirements  of  our  day,  and  usefully  disposed  of  the  colossal 
materials  within  my  reach. 

The  same  self-reliance  that  characterized  the  commencement  of 
my  pathologico-anatomical  studies,  has  stood  by  me  whilst  engaged 
in  observing  and  interpreting  the  facts  of  which  the  said  materials 
are  composed :  for,  each  individual  discovery  encouraged  me  more 
and  more  to  pin  my  faith  upon  ^Nature  alone.  Still  I  have  never 
failed  to  watch  and  to  appreciate  the  achievements  of  other  men. 

The  present  work  will  at  any  rate  tend  to  show,  how  thorough  is 
my  conviction  that  Pathological  Anatomy  must  constitute  the 
groundwork,  not  alone  of  all  medical  knowledge,  but  also  of  all 
medical  treatment ;  nay,  that  it  embraces  all  that  medicine  has  to 
offer  of  positive  knowledge,  or  at  least  of  what  is  fundamental  to  it. 
Its  domain  will  here,  however,  be  found  more  extended,  and  more 
nearly  approximated  to  the  confines  of  Pathological  Chemistry  than 
has  generally  been  the  case  in  pathologico-anatomical  writings. 

Upon  individual  sections  of  the  work  I  must  confess  to  have 
exercised  a  certain  favoritism ;  and  I  have  striven  to  cultivate  and  to 
carry  out  some  important  general  views,  with  a  well-tested  conviction 


X  AUTHOR    S    PREFACE. 

of  their  truth.  Amongst  these  views  I  may  here  single  out  for 
exemplification  the  doctrine  of  a  primitive  diversity  in  blastemata, 
as  the  only  tenable  basis  for  a  humoral  pathology. 

From  a  comparison  of  the  antecedently  published  volumes  on 
special  pathological  anatomy  with  the  present  one,  it  will  be  /'seen 
that  the  former  furnish  the  groundwork  of  the  views  here  pro- 
pounded, and  that  my  convictions,  upon  the  whole,  remain  un- 
changed. 

THE  AUTHOR 

VIENNA,  July,  1846. 


CONTENTS  OF  VOLUME  I. 


PAGE 

EDITOR'S  PREFACE,  ........        vii 

AUTHOR'S  PREFACE,    ........  ix 

INTRODUCTION,      .  .  .  .  .  .  .  .  .17 

CHAPTER  I. 
ANOMALIES  IN  RESPECT  OF  THE  NUMBER  OF  PARTS,         .  .  .  .35 

CHAPTER  II. 

ANOMALIES  OF  SIZE,         ........  42 

Abnormal  Magnitude,      .......  42 

Hypertrophy,  ........  42 

Abnormal  Diminutiveness,  ......  50 

Atrophy,        .........  51 

CHAPTER  III. 
ANOMALIES  OF  FORM,        ........        54 

CHAPTER  IV. 
ANOMALIES  OF  POSITION,  .  .  .  .  .  .  .  .57 

CHAPTER  V. 
ANOMALIES  OF  CONNECTION.         .......        59 

CHAPTER  VI. 

ANOMALIES  OF  COLOR,      ........        64 


Xll  CONTENTS. 

CHAPTER  VII. 

PAGE 

ANOMALIES  OF  CONSISTENCE,        .......        68 

CHAPTER  VIII. 
SEPARATIONS  OF  CONTINUITY,       .......        69 

CHAPTER  IX. 

ANOMALIES  OF  TEXTURE,  .......        70 

I.  Organized  New  growths,  .-  .  .  .  .  .  72 

A.  Of  Organized  New  growths  in  general,    .  .  .  .  .72 

Blastema  and  its  Metamorphoses  with  an  especial  reference  to  Fibrin,  78 

Coagulated  Fibrin,  .  .  .  .  .  .  .82 

Metamorphoses  of  Blastema,  .  .  .  .  .  86 

Hypersemia,          ........         91 

Hemorrhage,  .......  93 

Anaemia,  ........         98 

Inflammation,  Phlogosis,        .  .  4  .  .  .  98 

Varieties  of  Inflammation,  .  .  .  .  .  .105 

Relation  of  the  Inflammatory  Process  to  Crasis,         .  .  .  107 

Exudation,  .  .  .  .  .  .  .  .109 

Pus,  Ichor,      .  .  .  .  .  .  .  115 

Issues  of  Inflammation,    .  .  .  .  .  .  .124 

Gangrene,  Necrosis,    .  .  .  .  .  .  .  128 

Characteristic  of  Inflammatory  Textures  and  Diagnoses  of  Inflammation 

in  the  Dead  subject,  .  .  .  .  .  .  .132 

Corollary,        ........  133 

Deposits,  Metastasis  (so  called),  .....       134 

B.  Organized  New  growths, 

Specially  considered,        .  .  .  .  .  .  .136 

Areolar-tissue  Formations,      ......  137 

Fibroid  Texture,  .  .  .    '  .  .  .138 

Gluten  yielding  Fibroid  Tumor,      .  .  .  .  .  141 

Elastic  Tissue  and  Texture  of  the  Annulo-fibrous  Membrane  of  Arteries,       142 
Cartilaginous  Growths,  .  .  .  .  .  .  143 

Bone  Formation,  .......       144 

Growth  of  Bloodvessels,          ......  149 

Fat  Formation.  Fatty  degeneration,  .....  154 

Fat  Textures,      .  .  .  .  .  .  .  154 

Normal  Fat,         .  .  .  .  .  .  .154 

Abnormal  Fat,  .  .  .  .  .  .  .  155 

Free  Fats,  .  .....      156 

Epidermidal  and  Hair  Formations,    .  .  .  .  .  159 

Pigment  Formation,  .......  160 

Colloid, 166 

Cyst  and  Alveolus,  .  .  .  .  .  .  .168 

Sarcoma  and  Carcinoma,  .  .  .  .  .  .  189 

a.  Sarcomata,  190 


CONTENTS.  Xlll 


PAGE 


Cysto-sarcoma,        ....  . 

Appendix,         .....  194 

0.  Cancer.     Carcinoma,                .                                      .             .  196 

Colloid,  Gelatinous  Cancer.    Alveolar  Cancer  (C.  areolaire),  .  .       202 

Fibro-carcinoma  (Simple  Carcinoma),       ....  204 

Medullary  Carcinoma,               .             .            .             .             .  .207 

Cancer  Melanodes,               .             .             .             .                         .  213 

Typhous  Substance,      ...                         .  .215 

Villous  Cancer,       .                                       ....  216 

Epithelial  Growths,  Epithelial  Cancer,             .            .            .  .217 

Carcinoma  Fasciculatum,   .             .             .             .             .             .  219 

Cysto-carcinoma,           .             .             .             .             .             •  .219 

Appendix,  ....  .219 

Tubercle.     Tuberculosis,     ...                         .  •  .223 

Albuminous  Tubercle  (Acute  Tuberculosis),              .            .            .  245 
Albuminous  crude  Blastemata,      ......       247 

II.  Unorganized  New  growths,       ......  248 

A.  Of  Unorganized  New  growths  in  general,          ....       248 

B.  Of  Unorganized  New  growths  in  particular,              .             .             .  250 
First  Series,         .            .            .            .            .            .            .  .252 

Second  Series,            .            .            .            .            .             .            .  253 


CHAPTER  X. 

ANOMALIES  OF  CONTEXTS,             .            .                        .            .            .  .      254 

A.  Pneumatoses  and  Dropsy,           .             .             .             .             .             .  254 

B.  Foreign  Bodies,       ........       257 

c.  Parasites,             .             .             .             .             .             .             .             .  257 

I.  Parasite  Plants  (Epiphytes,  Entophytes),            .             .             .  .258 

1.  Fungi  within  and  upon  the  common  Integument,              .             .  258 

2.  Fungi  upon  Mucous  Membranes,        .             .             .             .  .259 

II.  Parasite  Animals  (Siebold),             .....  259 

1.  Infusoria,       ........       260 

2.  Insects,    ........  260 

3.  Arachnida.    Acarina,             .             .             .            .             .  .261 

4.  Intestinal  Worms.     Helminthes.     Entozoa,        .             .             .  261 

Nematoidea.     Round  Worms.     Thread  Worms,               .  .       263 

Trematoda.     Suction  Worms,              .             .             .             .  265 

Cestoidea.    Tape  Worms,             .            .            .            .  .265 

Cystica.     Vesicular  Worms,                ....  266 

Spurious  Parasites,           .            .            .            .            .            .  .     .  271 

Blood  Diseases.     Dyscrases,      .            .            .            .            .            .  271 

1.  Fibrin-erases,               .             .             .             .             ...  .       274 

a.  Simple  (Organizable,  Fibrinogenous)  Fibrin,               .             .  278 

b.  The  Croupous  Crasis  (Piorry's  Hasmitis),              .             .  .278 

Croupous  Crasis  («),               .             .             .             .,           .  279 

"          "     (/), 280 

"          "     GO, 281 

c.  The  Tubercle  Crasis,  ......       282 

Pyaemia.     Pus-blood,    .             .             .             .             .             .  285 

2.  Venosity.     Albuminosis.     Hypinosis  (Simon),            .             .  .       288 


XIV  CONTEXTS. 

PAGE 

a.  Plethora,            .......  289 

6.  The  Typhus-crasis,  .......  289 

c.  The  Exanthematous  Crasis,       .             .             .             .             .  292 

d.  Hypinosis  in  Diseases  of  Nerves,     .....  295 

e.  The  Drunkard's  Dyscrasis,         .             .             .             .             .  295 

f.  The  Crasis  of  Acute  Tuberculosis,  .....  297 

g.  Cancer  Dyscrasis,           .             .             .             .             .             .  298 

3.  Hydramia :  AnaBmia,  .  .  .  .  .  .301 

a.  The  Serous  Crasis.     Hydramia,            .            .            .            .  301 

5.  Anaemia,      ........  301 

4.  Decomposition.    Putrid,  Septic  Crasis.     Sepsis  of  the  Blood,       .  302 
Independent  Anomalies  of  the  Blood-Corpuscles,            .            .            .  305 


EXPLANATION  OF  THE  PLATES. 


PLATES  I.  AND  II. 

FIGS.  1  and  4  represent  proliferous  cyst-formations  from  the  cortical  substance  of  the 
kidney,  as  a  sequel  to  Bright's  disease.  The  two  figures,  1  and  4,  illustrate  well  Roki- 
tansky's  history  of  proliferous  cyst-development,  and  at  the  same  time  what  he  under- 
stands by  the  often-occurring  expression,  "alveolar  type  or  arrangement." 

In  fig.  1  we  have  the  cyst  in  all  its  phases,  a  is  a  simple  cyst,  arising  out  of  the 
expansion  of  the  elementary  granule,  first  into  the  nucleus,  from  this  into  the  cell,  and 
progressively  into  the  cyst.  But  it  has  remained  barren,  and  contains  only  a  diaphan- 
ous, viscid  serum  within  a  simple  cyst-membrane,  b  represents  a  parent-cyst,  the  early 
history  of  which  accords  with  that  of  the  barren  cyst ;  within  it,  however,  new  granules  have 
formed,  and  gradually  become  developed  into  vesicles  or  cysts  containing  other  nuclei, 
until  the  parent-cyst  has  become  replete  with  them,  and  from  being  spherical,  they  are 
rendered  polyhedrical  by  mutual  compression.  In  an  adjoining  parent-cyst,  many  of 
the  filial  cysts  have  remained  barren,  others  contain  nuclei  in  the  act  of  splitting,  c,  c. 
c,  c,  represent  another  form  of  development  of  the  parent-cyst.  Here,  again,  the  parent- 
cyst  has  gone  through  the  same  phases,  from  the  elementary  granule  upwards.  But,  as 
the  cell  dilates  into  the  cyst,  a  granule  forms  centrally  to  the  latter  and  expands  into  a 
filial  cyst,  centrally  to  which  a  third  granule  opens  out  in  the  same  manner ;  and  so  on. 
These  intra-cystic  cysts  in  their  dilatation  ultimately  close  upon  the  parent-cyst,  forming 
secondary,  tertiary,  and  ulterior  layers,  to  which  an  external,  fibrous  layer  is  generally 
added  out  of  the  surrounding  blastema.  Or  this  fibrous  coat  accrues  in  the  alveolar 
shape.  Fig.  1  affords  several  examples  of  this.  It  is,  however,  better  seen  in 

Fig.  4. — a  is  the  fibrous  sheath  in  progress  of  development  out  of  d,  the  elongated 
and  caudate  nuclei  coursing  around  the  parent-cyst  or  aggregation  of  parent-cysts. 
They  eventually  break  up  into  the  requisite  fibres,  e  is  to  represent  the  point-molecule, 
within  an  amorphous  blastema,  out  of  which  the  nuclei  (6)  form.  They  are  at  first  sphe- 
rical, afterwards  elongated,  and  ultimately  broken  into  fibrillation.  This  constitutes 
what  the  author  designates  as  the  "  alveolar  type  or  arrangement."  It  is,  however,  still 
better  defined  in, 

Fig.  2.  which  represents  cyst-formation  in  a  medullary  carcinoma.  From  the  carci- 
nomatous  framework  a  bulb-like  excrescence  is  thrown  out,  within  the  extremity  of 
which  a  parent-cyst  forms  and  becomes  replete  with  filial  cysts,  each  containing  a  cen- 
tral nucleus.  This  parent-cyst  surrounds  itself  with  a  broad  marginal  area  of  blastema, 
within  which  elongated,  caudate  nuclei  course  round  the  cyst  in  several  tolerably  regu- 
lar circles  or  series — the  rudiments  of  a  dense  fibrous  envelope.  Such  is  the  "  alveolar 
type,"  which  applies  to  the  fibrous  fabric  of  follicle  walls  as  well  as  to  those  of  cyst- 
formations.  (See  "  Cyst  and  Alveolus.") 

Fig.  3  represents  a  transverse  section  of  a  colloid  cancer,  a  is  an  older  portion  of 
densely  fibrillated  fibro-membranous  structure,  c  is  a  transverse  section  of  a  more 
recent  fibro-membranous  stroma;  &,  a  transverse  section  of  the  colloid  warp  which 
intertwines  with  the  said  fibro-membranous  stroma.  (See  p.  220.) 


xvi  EXPLANATION    OF    THE     PLATES. 

Fig.  8  represents  the  multilocular,  fibre-membranous  stroma  of  colloid  cancer  deprived 
of  its  colloid  contents.  (See  p.  221.) 

Figs.  5, 6,  and  7,  represent  so  many  stages  of  the  development  of  medullary  carcinoma. 
They  are  severally  described  in  the  same  order  in  which  they  are  here  numbered,  at 
pp.  220  and  221. 

Figs.  1,  2,  and  4  are  magnified  by  90  diameters,  the  five  remaining  figures  by  400 
diameters. 

Several  of  the  figures  here  given  are  embodied  from  Rokitansky's  "  Essays,"  in  Mr. 
Paget's  admirable  "  Lectures  on  Surgical  Pathology,"  vol.  ii. 

Figs.  1,  2,  and  4,  are  derived  from  Rokitansky's  Essay  on  "  Cyst  and  Alveolus,"  read 
before  the  Imperial  Academy  of  Sciences,  at  Vienna,  in  1849  j  figs.  3  and  8  from  his 
Essay  on  "  Colloid  Cancer,"  published  in  1852  ;  figs.  5,  6,  and  7,  from  a  thesis  of  his  on 
"  Cancer-stromata,"  also  published  in  1852. 


PLATE  I. 


Fig.  1 


PLATE  II. 


Fig.  5. 


Fig.  G. 


Fig.  7. 


INTRODUCTION. 


PATHOLOGICAL  ANATOMY  may  be  said  to  be  a  modern  science.  It  is 
indeed  only  of  late  years  that  it  has  assumed  the  dignity  of  an  inde- 
pendent science  at  all. 

Although,  according  to  Pliny,  dead  bodies  were  examined  in  Egypt 
at  the  time  of  the  Pharaohs,  that  is  to  say,  many  centuries  before 
Galen,  with  a  view  to  detect  the  seats  of  disease ;  the  result  of  those 
researches  has  remained  unrevealed  to  us.  Even  upon  Greek  medicine 
the  pathologico-anatomical  observations  made  by  its  founders  and 
scholars  have  been  without  material  influence.  They  were  indeed  gra- 
dually lost  sight  of  in  the  medical  schools,  which  arose  out  of  the  suc- 
cessive systems  of  philosophy  of  a  later  period. 

Not  until  the  commencement  of  the  sixteenth  century — the  period  of 
the  regeneration  of  anatomy — does  the  epoch  begin  of  an  occasional, 
fragmentary,  indeterminate  study  of  pathological  anatomy.  Still, 
Eustachius,  the  rival  of  Vesalius,  must  have  been  deeply  impressed  with 
its  importance ;  for,  towards  the  close  of  his  life  he  expresses  his  regret 
that  he  had  not  rather  bestowed  upon  pathological  anatomy  that  time 
and  attention  which  he  had  devoted  to  physiological  anatomy.  The 
first  who  dedicated  himself  in  an  especial  manner  to  pathological 
anatomy  was  Antony  Benivieni,  who  wrote,  at  Florence,  "  De  abditis 
morborum  causis"  (1507).  He  was  followed  by  Mathieu-Reald  Co- 
lumbus, the  protector  of  Vesalius  (1590),  Volcher  Goiter,  a  disciple  of 
Fallopius  (1573),  Salius  Diversus  (1584),  Marcellus  Donatus  (1588). 
Johannes  Schenkins  collected  the  observations  made  up  to  his  time 
(1584).  Johannes  Wierus  (1569),  Felix  Plater  (1614),  Fabricius  Hil- 
danus  (1606),  Tulpius  (1672),  Vesling  (1664),  Thomas  Bartholin  (1654- 
1675),  Stalpaart  van  der  Wiel  (1677),  Daniel  Sennert  (1676),  Friedrich 
Ruysch  (1691),  cultivated  pathological  anatomy  after  their  own  fashion. 
Their  observations,  although  partially  of  great  interest,  often  bear  the 
impress  of  superstition,  and  are  disfigured  by  the  fanciful  way  in  which 
they  are  interpreted. 

Since  the  time  of  Harvey,  the  discoverer  of  the  circulation,  who,  in 
denominating  our  particular  science,  medical  anatomy,  showed  how 
fully  he  comprehended  its  import,  various  physicians  have  worked  out 
sundry  branches  of  pathology  anatomically.  Amongst  them  are 
Thomas  Willis  (1677)  and  J.  J.  Wepfer  (1658-1727).  Others,  as 
Fernel  (1679),  F.  Sylvius  (1734),  Baillou  (1735),  have,  in  their  com- 


VOL.  I. 


>  0  •      9  »      a 

18  INTRODUCTION. 

pendia  of  pathology,  adopted  pathological  anatomy  for  their  ground- 
work. Bonnet  was,  however,  the  first  who  compiled  an  ample  repertory 
on  this  subject  ("  Sepulchretum,"  1679) ;  and  even  this  work  unites  to 
the  imperfections  of  earlier  observations  the  lack  of  a  standard  physio- 
logical principle,  and  of  a  definite  practical  tendency.  The  same 
applies  equally,  if  not  more  forcibly,  to  Blankaard's  "Anatomia  prac- 
tica"  (1688). 

Above  both  these — above  all  that  had  been  previously  accomplished 
— stands  pre-eminent,  Morgagni  and  his  work,  "  De  sedibus  et  causis 
morborum"  (1767).  Notwithstanding  its  defects,  this  book  remains  a 
model  of  industry  and  perseverance,  of  method  and  arrangement,  of 
breadth  and  perspicuity,  and,  lastly,  of  originality,  for  all  time. 

In  the  same  century,  special  investigations,  not  unworthy  of  record, 
were  made  by  J.  Moritz  Hofman,  Walter,  Albinus,  Vater,  Levret,  W. 
Hunter,  Senac,  Meckel,  Bbhmer,  Van  Doeweren,  Camper,  Bleuland, 
and  others. 

In  a  work  containing  a  vast  number  of  facts  ("  Historia  anatomico- 
medica,"  1768),  the  purpose  attained  by  Morgagni,  failed  in  Lieutaud's 
hands,  through  lack  of  detail,  of  analysis,  of  a  practical  generalization 
of  facts.  On  the  other  hand,  Sandifort  ("  Observ.  anat.  path.,  1777) 
merits,  for  the  richness  and  solidity  of  his  writings,  to  be  classed  along 
with  Morgagni.  4 

The  compendia  published  in  1785,  by  C.  T.  Ludwig,  and  in  1796,  by 
Conradi,  and  even  the  greater  work  of  Voigtl  (1804),  so  marked  by 
literary  industry  and  so  serviceable  withal,  have  not  advanced  science, 
either  by  aptness  of  discrimination,  by  a  judicious  selection  of  matter, 
nor  yet  by  any  remarkable  progress  in  the  method  of  anatomical 
research. 

Mathew  Baillie's  anatomy  of  morbid  structures  (translated  into  Ger- 
man by  Soemmering,  in  1794)  is  distinguished  by  greater  depth  of 
research  into  the  fabric  of  organs,  and  both  by  its  generalizing  tendency 
and  its  physiological  character.  These  latter  qualities  are,  however, 
still  more  decidedly  impressed  upon  the  aphorisms  from  pathological 
anatomy  published  at  Vienna,  by  Velter,  in  1805. 

The  most  decided  impulse  was  given  to  a  right  conception  and  appli- 
cation of  pathological  anatomy  by  Bichat  in  his  general  anatomy. 
Bichat  founded  upon  the  latter  an  especial  physiology,  or  rather, 
blended  the  two.  Pathologists,  imitating  this,  endeavored  to  recon- 
struct their  science  upon  an  anatomical  basis. 

France  was  the  country  in  which  this  attempt  was  made  in  the  most 
effectual  manner ;  not  that  it  was  exactly  the  cradle  of  pathological 
anatomy,  but  that  it  was  the  land  of  all  others,  in  which  men  sought 
and  found  in  it  a  solid  foundation  for  medical  knowledge.  Such  men 
were,  amongst  others,  Bayle,  Corvisart,  Laennec,  Dupuytren,  Broussais, 
Cruveilhier,  Rochoux,  Lallemand,  Eiobd,  Andral,  Louis,  Gendrin, 
Bouillaud,  Billard,  Rayer.  4  It  is  true  that  one  of  these,  namely, 
Broussais,  disseminated  an  error  from  which  his  pupils  cannot  yet 
disentangle  themselves,  an  error  in  which  Brunonianism  seemed  once 
more  to  be  trying  its  strength  upon  novel  ground.  On  the  other  side, 
however,  Laennec  invented  and  carried  out  a  method  which  insures  to 


INTRODUCTION.  19 

him  and  to  his  work  the  acknowledgment  and  admiration  of  future 
ages. 

In  England  many  have,  up  to  our  own  day,  worked  in  a  similar  spirit. 
Amongst  these,  we  may  mention  the  names  of  Abernethy,  Charles  Bell, 
Astley  Cooper,  Hodgson,  Farre,  Wardrop,  Howship,  Baron,  Hodgkin, 
Hope. 

In  Italy,  on  the  contrary,  and  in  Germany — if  we  except  the  impulse 
so  decisively  given  in  the  same  direction  by  the  ingenious  Reil — patho- 
logical anatomy  has  been  upon  the  whole  less  cultivated,  and  has  exer- 
cised less  influence  upon  medicine.  Accordingly,  Germany  and  Italy 
have  but  few  men  to  place  in  parallel  with  those  of  France ;  few  to  add 
to  the  names  of  Scarpa,  Malacarne,  Paletta — of  J.  F.  Meckel,  Otto, 
and  (in  industry  and  method,  the  essentially  German)  Lobstein. 

It  was  reserved  for  Germany,  at  the  present  day,  to  establish  a 
pathological  anatomy  and  a  method  of  working  it  out,  partly  indepen- 
dent, partly  framed  according  to  the  best  models  of  France.  Under 
the  auspices  of  German  universality  and  analysis,  this  renovated  science', 
emancipated  alike  from  the  systems  of  a  bygone  age  and  from  a  vain 
eclecticism,  has  begun  to  incorporate  itself  with  pathology  in  a  way 
that  promises  both  durability  and  brilliant  progress,  more  especially  in 
its  natural  alliance  with  German  physiology,  and  under  a  consistent  and 
rational  standard  of  pathological  chemistry. 

Classification. — Just  as  there  is  a  general  and  a  special  anatomy, 
physiology,  pathology,  so  there  must  in  like  manner  be  a  general  and  a 
special  pathological  anatomy.  The  former  treats  of  general  anomalies 
of  organization,  the  latter  of  the  special  anomalies  of  individual  tex- 
tures and  organs. 


All  anomalies  of  organization  involving  any  anatomical  change 
manifest  themselves  as  deviations  in  the  quantity  or  quality  of  organic 
creation,  or  else  as  a  mechanical  separation  of  continuity.  They  are 
reducible  to  irregular  number  [deficient  or  excessive  formation],  irre- 
gular size,  form,  position,  connection,  color,  consistence,  continuity, 
texture,  and  contents.  They  relate  to  the  physical  properties  of  the 
animal  body  and  of  its  organs.  The  chemical  properties,  although  not 
strictly  pertaining  to  the  field  of  anatomy,  are  too  intimately  connected 
with  the  physical,  to  be  suffered  to  remain  in  the  background  at  the 
present  day.  The  animal  fluids  bear  a  similar  relation  to  anatomy. 
Their  anomalies  will  be  taken  into  account,  so  far  as  it  may  appear 
needful,  under  the  appropriate  heads.  Those  of  the  sanguineous  fluid 
will,  however,  demand  a  separate  chapter.  This  will  come  in  at  the 
conclusion  of  the  general  anatomy,  in  which  a  frequent  reference  to 
them  will  have  previously  demonstrated  the  indispensable  nature  of  the 
inquiry,  as  a  sort  of  connecting  link  between  general  and  special 
anatomy.  "We  shall  thus  have  to  discuss,  in  ten  separate  chapters,  the 
anomalies  of  organization.  There  are,  however,  a  few  general  points 
which  require  some  previous  explanation. 


20  INTRODUCTION. 

I.  The  said  anomalies,  being  simple  alterations  of  the  normal  being 
and  of  its  parts,  appear  as  abnormal  conditions,  excluding  the  idea  of 
an  independent  parasitic  organism  of  disease. 

II.  No  formation  is  incapable  of  becoming  diseased  in  one  or  more 
ways.     Several  anomalies  coexisting  in  an   organ  commonly  stand  to 
each  other  in  the  relation  of  cause  and  effect.     Thus,  deviations  in  tex- 
ture very  frequently  determine  deviations  in  size,  in  form, — and  these 
again  deviations  in  position.     Deviations  in  position  give  rise  to  anoma- 
lies of  volume  and  of  texture. 

III.  Pathological  anatomy,  proximately  concerned  with  anomalies  of 
individual  organs  and  systems — with  local  anomalies — has  often  reserved 
for  it  the  task  of  revealing  by  experiment  and  deduction  the  existence 
of  general  disease,  as  also   of  establishing  the  mutual  relations  which 
exist  between  the  two.     The  seat  of  general  diseases  may  now  be  refer- 
red, almost  without  exception,  to  the  blood  [the  fluids].     They  appear, 
therefore,  as  anomalies  of  admixture  or  crasis,  either  primary  or  secon- 
dary. 

IV.  This  demonstration  of  general  disease  is  indeed  a  step  in  advance 
for  pathological  anatomy.     It  threatens,  however,  to  mislead  us  into  the 
error  of  exclusive,  transcendental,  all-pervading  humoralism — into  the 
error  of  denying  all  local  disease,  by  deducing  the  latter  in  every  in- 
stance from  a  corresponding  general  affection, — not  but  that  many  dis- 
eases really  are  but  the  localization  of  a  pre-existent  general  disease. 

V.  The  existence  of  purely  local — independent  of  general — disease, 
from  the  simplest  inflammation — from  blennorrhoea,  to   tubercle  and 
cancer,  we  look  upon  as  grounded — 

(a.)  In  the  self-vitality  of  organs,  and  their  independent  relations  to 
the  external  world. 

(b.)  In  the  local  influence  of  direct  or  reflected  stimulation.  Either 
directly,  or  through  the  medium  of  the  nervous  system,  stimuli  effect  a 
local  modification  in  the  vital  processes  of  absorption  and  secretion — in 
the  interchange  of  matter, — an  anomalous  reciprocity  between  bloodves- 
sels and  their  contents  on  the  one  side,  and  the  parenchyma-engendering 
products,  abnormal  both  in  quantity  and  in  kind,  on  the  other. 

Normal  nutrition  and  secretion  are  no  doubt  mainly  dependent  upon 
a  normal  crasis ;  but  they  are  also  based  upon  the  perfection  of  the  spe- 
cific vital  action  proper  to  individual  parenchymata.  Anomalous  secre- 
tions often  arise  out  of  influences  which  modify  the  vital  action  of  the 
parenchyma,  and  consequently  its  reciprocity  with  the  unchanged  gross 
material,  the  blood:  as,  for  example,  augmented  or  otherwise  altered 
secretion  of  milk,  produced  by  local  irritation  or  by  anomalous  innerva- 
tion,  the  effect  of  mental  operations.  In  like  manner,  local  diseases  are 
but  a  consequence  of  qualitative  and  quantitative  alienation  of  the  tex- 
tures and  organs, — the  formative  material  (the  blood),  notwithstanding 
its  reciprocity  with  the  latter,  not  becoming  sensibly  contaminated. 

Influences,  especially  of  a  mechanical  kind,  are  often  so  strictly  local, 
that  it  would  be  far-fetched  to  derive  all  local  disorder  from  a  general 
causal  disease.  Even  the  latter  would  be  but  secondary, — a  mere 
transfer  of  the  alienation  locally  produced. 


INTRODUCTION.  21 

The  existence  of  local  diseases  is  further  shown — 

(c.)  By  direct  evidence,  where  local  disease  is  established,  of  the  ab- 
sence of  any  disease  of  the  blood  crasis. 

(d.)  In  the  curableness  by  topical  remedies — extirpation,  isolation, 
&c. — of  local  diseases,  without  their  recurrence  either  on  the  same  spot 
or  elsewhere.  The  cure  may  even  involve  the  simultaneous  removal  of 
a  general  disease  consequent  upon  the  local  one,  this  having  possibly 
acted  as  an  anomalous  instrument  for  the  elimination  of  certain  elements 
from  the  blood,  exhausting  it  of  certain  essential  constituents. 

VI.  Local  disease  extends  beyond  its  original  seat  in  various  ways : 

1.  By  contiguity.     The  affection  spreads  to  the  immediate  vicinity  of 
its  original  seat.     This  extension  is  favored — 

(a.)  By  uniformity  of  structure. 

(5.)  By  intensity  of  disease. 

(c.)  By  the  nature  of  the  malady.  Certain  diseases,  such  as  tubercu- 
losis and  cancer,  in  their  extension,  spare  no  texture,  whilst  the  typhous 
process  upon  the  intestinal  mucous  membrane  always  finds  an  arresting 
formation  in  the  sub-mucous  areolar  tissue. 

2.  The  disease  extends  to  remote  formations,  both  similar  and  dis- 
similar.    This  mode  of  diffusion  does  not  imply  concurrent  general  dis- 
ease, but  proceeds,  according  to  tolerably  constant  laws  of  sympathy, 
through  the  mediation  of  the  nerves.     It  is  greatly  promoted,  however, 
by  a  concurrent  general  disease,  kindred  in  character  with  the  local, 
causing  it  to  increase,  and  multiplying  the  seats  of  the  disease,  as,  for 
instance,  in  inflammation. 

VII.  The  originally  mere  local  is  enhanced  into  a  general  disease  of 
the  same  nature,  or  gives  rise  to  one  of  different  attributes.     The  former 
contingency  may  arise  from  the  alienation  of  the  peripheric  nerves,  pro- 
ductive of  the  local  anomaly,  being  transmitted  to  the  nervous  instru- 
ments presiding  over  the  circulation, — in  other  words,  to  the  nervous 
centres,  and  in  particular  to  the  spinal  cord  and  the  ganglia.     Or  else 
the  conversion  assumes  the  substantive  form  of  infection,  the  noxious 
matter  evolved  by  the  original  local  disease,  or  its  products,  being  re- 
ceived into  the  circulation.     This  last  event  occurs  where  the  products 
of  the  local  disease  exhaust  the  blood  of  certain  ingredients,  for  in- 
stance, of  fibrine,  of  albumen,  of  serum,  of  salts.     To  this  class  belong, 
in  like  manner,  the  anomalies  occasioned  by  mechanical  disproportion, 
such  as  the  venous  diathesis,  cyanosis  dependent  upon  disease  of  the 
heart  or  lungs,  &c. 

VIII.  The  presence  of  general   disease   may   be   the   more   safely 
inferred : 

1.  The  more  widely  extended  is  the  local  disease  over  several  uniform 
or  dissimilar  formations,  and  the  greater  its  intensity. 

2.  The  less  the  products  of  the  local  process  are  conformable  with  the 
character  of  the  normal  structures  ; 

3.  The  less  the  extent  and  nature  of  the  local  disease,  or  of  the  struc- 
tures involved,  however  important  in  the  organism,  suffice  to  account  for 
the  general  appearances  during  life  and  after  death ; 


22  INTRODUCTION. 

4.  The  more  anomalous,  compared  with  the  alienation  of  the  solids, 
are  the  secretions  and  excretions  ;  and, 

5.  The  more  the  totality  of  the  organism,  in  the  absence  of  actual 
anatomical  disturbances,  seems  cachectic  and  impaired. 

6.  The  more  marked  is  some  anomaly  in  the  circulating  fluid,  with 
respect  to  the  quantity  or  quality  of  its  component  parts. 

IX.  General  disease  engenders  in  the  most  various  organs  and  tex- 
tures, according  to  their  innate  general  or  individual  tendencies,  either 
spontaneously  or  by  dint  of  some  overpowering  outward  impulse,  a  local 
affection  which  reflects  the  general  disease  in  the  peculiarity  of  its  pro- 
ducts.    The  general  disease  becomes  localized,  and,  so  to  speak,  repre- 
sented, in  the  topical  affection. 

X.  A  general  disease  not  unfrequently  finds  in  its  localization  a  per- 
petual focus  of  derivation,  with  seeming  integrity  of  the  organism  in 
other  respects.     Recovery  may,  after  a  lengthened  process,  eventually 
take  place  through  the  exhaustion  of  materials  at  the  local  vent.     Forced 
extirpation,  on  the  contrary,  or  insulation  of  the  locality,  generally 
aggravates  to  a  high  degree  the  general  disease,  multiplying  its  points  of 
localization. 

XI.  The  disease  has,  even  anatomically  speaking,  its  stages  of  inci- 
piency,  increment,  acme,  and  decline.    - 

XII.  The  terminations  of  disease  are,  in  like  manner,  subjects  for 
anatomical  research. 

1.  The  issue  of  local  disease  in  health  consists  either  in  the  perfect 
re-establishment  of  the  normal  condition,   or  else  in  partial  recovery ; 
more  or  fewer  important  residua  and  sequelae  of  the  disease,  not  incom- 
patible with  a  tolerably  fair  state  of  health,  remaining  entailed.     Thus 
the  previously  diseased  organ  may  have  lost  substance,  or  more  or  less 
its  natural  texture  ;  or  it  may  have  suffered  changes  in  form  or  in  posi- 
tion, or  interruptions  of  continuity. 

2.  The   issue   of    one   general   disease   in   another   general   disease 
[metaschematismus]  is  frequent.     Anatomical  research  proves,  and  che- 
mical analysis  will  still  more  clearly  demonstrate,  that  it  is  far  more  fre- 
quent and  varied  than  would  appear  from  mere  clinical  observation. 
This  is  taught  in  an  especial  manner  in  the  mutual  exclusion  of  different 
morbid  processes,  which  seem  to  succeed  each  other,  when  in  full  vigor, 
sometimes  almost  by  a  necessary  sequence.     Thus  dropsy  may  succeed 
to  the  exhaustion  of  fibrine  and  the  excretion  of  albumen,  cancer  to 
tubercle,  &c. 

3.  Transition  by  so-called  metastasis  often  becomes  the  subject  of  the 
scalpel.     It  comprises  various  conditions : 

(a.)  The  localization  of  a  general  disease  at  an  unusual  spot.  It  has  the 
character  of  a  vicarious  or  supplementary  crisis.  Instances  are  afforded 
in  skin  eruptions,  and  especially  in  the  secondary  typhous  processes. 

(b.)  Topical  processes  constituting  the  localization  of  a  metaschema- 
tism,  with  which,  as  in  the  former  instance,  a  general  disease  concurs. 
Such  metastases  occur  more  particularly  in  the  sequel  of  typhus,  and  in 
the  shape  of  inflammation,  suppuration,  gangrene,  in  both  external  and 


INTRODUCTION.  23 

internal  organs.  They  represent  the  localization  of  a  general  disease 
consecutive  to  the  original  typhous  process. 

(c.)  Local  processes,  with  the  development  of  which  the  general  dis- 
ease is  essentially  abated,  or  thoroughly  exhausted  and  extinguished. 
They  are  frequent,  and  deserve  alone  to  be  designated  as  metastases, — 
metastases  in  a  restricted  sense.  They  are  either  just  sufficient  vents 
for  the  general  disease,  and  are  only  cured  when  the  latter  is  subdued ; 
or  they  heal  spontaneously,  the  dyscrasis  having,  through  their  agency, 
become  exhausted. 

(d.)  When,  owing  to  whatever  cause,  a  local  disease  has  been  checked 
in  its  development,  it  subsides  only  to  reappear  in  another  part,  often 
with  augmented  force,  and  with  the  supervention  of  a  new  general  dis- 
ease, or  the  aggravation  of  one  already  existent. 

4.  Issue  in  death.     Diseases  are  mortal  for  the  most  part, 

(a.)  Through  exhaustion  of  power  and  of  organic  matter,  tabescence, 
loss  of  fluids. 

(b.)  Through  the  suspended  function  of  organs  essential  to  life; 
through  palsy ;  through  sudden  and  extensive  displacements ;  through 
hypertrophy,  atrophy,  diseases  of  texture. 

(c.)  Through  vitiation  of  the  blood  and  palsy  of  the  nervous  centres 
arising  out  of  the  conflict  between  contaminated  blood  and  nervous 
medulla. 

XIII.  Where  several  diseases  coexist  in  an  individual,  they  are  in 
part  primary,  in  part  secondary  and  subordinate  to,  although  homolo- 
gous with,  the  former.     Again,  they  are  partly  sequelae  and  residua  of 
antecedent  disease,  as  in  the  case  of  atrophy  of  the  brain  consequent 
upon  apoplexy,  upon  encephalitis. 

XIV.  Very  dissimilar  anomalies  may  coexist  in  one  individual,   as 
mere  local  affections  or  complications.     Combination  or  exclusion  result 
only  in  the  case  of  heterogeneous  diseases  founded  in  or  determining  a 
dyscrasis  :  for  example,  cancer  and  tubercle,  organic  heart  disease  and 
tuberculosis.     The  study  of  these  two  relations  opens  a  rich  field  of 
promise  for  the  furtherance  of  accuracy  in  diagnosis. 

XV.  The  import  of  a  disease  bears  a  direct  ratio  to  the  worth  of  the 
organs  attacked:  take,  for  example,  hypertrophy  in  different  muscular 
organs. 

XVI.  With  reference  to  the  period  during  which  anomalies  originate, 
we  have  to  distinguish  congenital,  or  such  as  have  become  established 
during  intra-uterine  life,  and  acquired,  or  such  as  have  arisen  during 
extra-uterine  life.     The  former  comprehend  primitive  anomalies. 

XVII.  Primitive  anomalies  comprise  malformations.     These  are  de- 
viations of  the  organism,  or  of  an  organ,  so  intimately  blended  with  its 
primary   development,    as   to   occur   only   at   the    earliest   periods  of 
embryonic  life,  or  at  any  rate  before  that  of  mature  foetal  existence. 

Malformations,  when  inconsiderable  and  harmless  to  the  individual, 
are  termed  lusus  naturce,  variation,  defect  of  formation,  malformation; 
when  more  marked,  deformity ;  when  excessive,  misbirth,  monstrosity, 
monster. 


24  INTRODUCTION. 

Despite  some  progress  made  in  this  field  of  late  years,  the  genesis  of 
malformation  is  still  veiled  in  much  obscurity.  The  opinions  of  modern 
physiologists  on  this  point  may  be  collected  under  two  heads.  Accord- 
ing to  the  one  section,  the  malformations  are  referable  to  a  primitive 
malformation  of  the  germ.  According  to  the  other,  to  various  influences 
affecting  the  germ  in  the  progress  of  development. 

The  former  opinion  resolves  itself  into  that  of  the  ovists  and  that  of 
the  spermatists.  Those  believed  in  the  foreshadowing  of  the  malforma- 
tion in  the  ovum ;  these  regarded  it  as  dependent  upon  the  spermatozoa 
as  embryones. 

At  this  day  both  theories  are  rejected  as  inapplicable  to  a  vast  num- 
ber of  malformations  which  unquestionably  do  originate  during  the  de- 
velopment of  the  germ.  Still  the  malformation  might  be  founded  in 
the  nature  of  the  ovum  and  of  the  sperma,  although  neither  of  these 
constitutes  the  embryo.  The  frequent  recurrence  of  the  same  malfor- 
mations out  of  the  same  parents,  and  the  hereditary  character  of  these 
anomalies,  render  this  not  improbable.  We  might  further  advert  to  the 
nature  of  certain  malformations — inversions,  duplicate  formations,  for 
instance — in  which  the  fusion  of  two  germs,  and  the  bisection  of  a  single 
germ,  during  their  development,  are  neither  of  them  quite  conceivable. 

The  second  of  the  aforesaid  propositions  embraces  several  hypotheses. 

(a.)  The  oldest  and  most  popular  ^attributes  the  malformation  to  a 
sudden  and  forcible  impression  wrought  upon  the  mother  (Yerschen). 
The  question  whether  mental  emotions  do  influence  the  development  of 
the  embryo  must  be  answered  in  the  affirmative.  Instances  undoubtedly 
have  occurred  of  such  maternal  impressions — fright  more  particularly — 
when  violent,  giving  rise  to  malformations.  Seeing  that  many  malfor- 
mations originate  in  an  arrest  of  development,  and  how  frequently  the 
former  bear  a  certain  resemblance  to  various  animals,  it  is  just  conceiv- 
able that  the  development  of  the  embryo  may  be  so  arrested  by  mater- 
nal emotions  as  accidentally  to  occasion  a  likeness  between  the  object 
that  produced  the  impression  and  the  resulting  malformation. 

(6.)  A  second  doctrine  derives  malformation  from  external  mechanical 
influences,  such  as  a  blow,  a  thrust,  a  fall,  &c.,  suffered  by  the  mother ; 
mechanical  obstacles  to  the  passage  of  the  ovum  through  the  Fallopian 
tubes,  and  to  its  growth  in  the  womb ;  excess  or  deficiency  of  liquor 
amnii ;  restriction  of  space  for  the  foetus ;  the  formation  of  false  mem- 
branes within  the  cavity  of  the  amnion,  &c.  Although  F.  Meckel  dis- 
sents from  this  doctrine,  we  are  not  quite  prepared  to  relinquish  it  our- 
selves. 

(<?.)  A  third  opinion  assigns,  as  the  cause  of  malformations,  disease  of 
the  foetus. 

Disease  arrests  the  development  of  foetal  formation  with  respect  to 
growth,  shape,  position,  and  texture  of  particular  organs,  indirectly  em- 
barrassing the  expansion  of  neighboring  organs,  or,  it  may  be,  causing 
their  destruction.  A  common  disease  having  this  tendency  is  dropsy, 
as  preventive  of  union  or  closure,  and  productive  of  disjunction  or  fis- 
sure. Inflammation  and  its  consequences  may  be  mentioned  under  the 
same  head. 

The  conditions  of  encephalocele,  of  hemicephalus,  of  anencephalus, 


INTRODUCTION.  25 

and  of  spina  bifida,  being  obviously  due  to  dropsy,  are  beyond  the  pale 
of  arrested  formation.  Certain  anomalies  of  the  peritoneum  and  of  its 
viscera,  formerly  reckoned  as  genuine  instances  of  arrested  formation, 
have  been  shown  by  Simpson  in  certain  instances  probably  to  result 
from  foetal  inflammation.  Some  malformations  of  the  heart,  especially 
defects  in  its  septa,  we  hold  to  be  owing  to  fcetal  endocarditis,  and  to 
consequent  coarctation  of  the  heart's  orifices. 

The  number  of  malformations,  however,  to  which  this  doctrine  fully 
applies,  is  as  yet  very  small.  Amongst  those  which  do  not  admit  of 
such  an  explanation  are  duplicate  formations,  and  the  great  majority  of 
malformations  designated  by  the  term  malposition. 

(d.)  The  fourth  proposition — which  the  countenance  given  to  it  by 
Wolff,  by  Tiedemann,  and  especially  by  J.  F.  Meckel,  has  caused  to  be 
the  more  generally  received  one — has  formed  the  groundwork  for  an 
elaborate  scientific  inquiry  into  the  subject,  in  especial  connection  with 
the  history  of  development.  This  sets  forth  that  most  malformations 
represent  certain  stages  of  the  development  of  the  embryo  and  of  its  or- 
gans, at  which  stages  formation  has  stopped  short,  or  from  which  ulterior 
development  has  ceased  to  follow  the  normal  type.  The  malformation  is 
therefore  essentially  an  arrest  of  development. 

This  theory  of  malformations  is  in  a  great  measure  correct.  Still  it 
does  not  attempt  to  explain  the  cause  of  the  arrest,  which  may  be  one 
of  those  already  enumerated,  be  it  concerned  with  the  germ,  with  sick- 
ening of  the  embryo,  with  mechanical  influence,  or  with  mental  emotion. 

A  good  classification  of  malformations  is,  owing  to  the  difficulty  of 
establishing  a  principle  of  division  generally  applicable,  as  yet  wanting. 
If  we  attempt  to  classify  them  according  to  external  form,  we  meet  with 
a  barrier  in  their  multiplicity.  Another  obstacle  consists  in  this,  that 
where  several  malformations  coexist  in  the  same  individual,  they  must 
needs  all  be  classified  according  to  the  one  most  pronounced,  and  the 
designation  be  therefore  partially  incorrect.  A  classification  founded 
upon  the  occasional  causes  is  impracticable,  since  the  same  malformation 
may  originate  from  various  causes.  If  we  take  for  the  basis  external 
form  and  cause  conjointly,  the  classification  becomes  bereft  of  logical 
unity. 

It  is  desirable  that  we  should  become  acquainted  with  the  principles 
upon  which  the  more  remarkable  classifications  hitherto  propounded  are 
built. 

Passing  over  the  older  classifications,  we  should  except  that  of  Buffon, 
as  it  forms  the  groundwork  upon  which  almost  all  the  latter  ones  are 
modelled.  Buffon  divided  malformations  into  three  classes :  1,  malfor- 
mation with  excess ;  2,  with  deficiency ;  3,  with  inversion  or  perverse 
site.  To  this  classification  we  may  subjoin  that  of  Blumenbach,  under 
the  following  four  heads  :  1,  fabrica  aliena ;  2,  situs  mutatus  ;  3,  mon- 
stra  per  excessum ;  4,  monstra  per  defectum.  These  were  followed  by 
Meckel  in  his  division  of  malformations,  as  follows :  1,  malformation 
from  deficient  plastic  power ;  2,  from  excess  of  plastic  power ;  3,  from 
deviation  of  the  organs  in  respect  to  their  natural  form ;  4,  malforma- 
tions characterized  by  ambiguity  of  sex — hermaphroditism.  This  dis- 


26  INTRODUCTION. 

tinction  of  hermaphroditism  from  other  malformations  constitutes  the 
great  defect  of  Meckel's  classification. 

Breschet  has,  in  his  classification,  broken  up  Buffon's  first  class  into 
two,  by  separating  duplicate  formations  from  malformations  per  exces- 
sum.  The  four  orders  of  his  classification  are :  1,  ageneses,  devious  for- 
mations with  diminution  of  plastic  power ;  2,  hypergeneses,  with  aug- 
mentation of  plastic  power ;  3,  diplogeneses,  devious  formations  with  the 
fusion  of  germs — duplicate  formations ;  4,  heterogeneses,  with  alien  cha- 
racter of  the  product  of  generation.  The  further  division  is  as  follows  : 

The  first  order,  ageneses,  breaks  up  into  four  species. 

(a.)  Agenesie,  absence — defective  development.  It  is  either  partial, 
as  in  hemicephalie,  aprosopie,  acephalie,  apleurie ;  or  it  is  gene- 
ral, as  in  microsomatie  (dwarfishness,  cretinism). 

(b.)  Diastematie,  cleft  formation  at  the  median  line.  It  is  subdivided 
•according  as  it  affects  the  head  or  the  trunk,  into  diastemence- 
phalie,  &c.,  and  diastematosternie,  &c. 

(c.)  Atresie. 

(d.)  Symphysie,  coalition  fusion. 

The  second  order,  hypergenese,  presents  two  species,  according  as  in- 
dividual parts  or  the  entire  body  are  concerned.  To  the  former  species 
belong  macrocephalie,  macroprosopie,  <^c. ;  the  latter  consists  of  macro- 
somatie  (giant  growth). 

The  third  order,  diplogenese,  is  divisible  into  external,  through  fusion 
or  adhesion,  as  in  diplocephalie,  diplothoracie ;  and  internal,  through 
penetration  (per  penetrationem). 

The  fourth  order  has  three  species. 

(a.)  Deviation  as  to  site,  either  of  the  entire  organism  [extra-uterine 

pregnancy]  or  of  individual  organs  [ectopie]. 
(b.)  Deviation  as  to  number,  polypsedie — the  coexistence  in  the  uterus 

of  several  foetuses. 
(<?.)  Deviation  as  to  color — leucopathie,  cyanopathie,  cirrhopathie. 

In  this  arrangement,  the  distinction  of  dip-ogenesis  from  hypergenesis 
is  based  upon  the  unproved  doctrine  of  the  fusion  of  two  germs  constitut- 
ing duplicate  formation.  To  the  order,  heterogenesis,  are  referred  devi- 
ations which  ought  not  to  be  designated  as  malformations. 

One  of  the  best  known  classifications  of  late  years  is  that  of  the  two 
Geoffroy  St.  Hilaires,  father  and  son,  who  handle  malformations,  accord- 
ing to  the  natural  method,  under  the  term  teratology  (from  repas,  mon- 
strum). 

Malformations  are  simple  and  complex — anomalies  simples  et  com- 
plexes. 

The  simple — he'mite'ries — are  either  so-called  variations,  lusus  naturae, 
where  the  anomaly  is  slight,  causing  neither  disturbance  of  function  nor 
deformity,  or  else  defects  of  conformation,  malformations  in  a  restricted 
sense,  where,  however  trifling  the  anatomical  deviation,  they  impede  or 
preclude  the  exercise  of  one  or  more  functions,  or  occasion  deformity. 

They  are  divided  into  five  classes,  the  anomaly  being  respectively  con- 
cerned with — 


INTRODUCTION.  27 

1.  Volume,  as  regards  size,  both  of  the  body  generally,  and  of  its  in- 

dividual parts ; 

2.  Form; 

3.  Structure  and  coloration ; 

4.  Disposition; 

5.  Number  and  existence,  that  is  absence  or  presence  of  parts. 

These  classes,  according  to  extent  and  to  degree — according  to  the 
kind  of  malformation,  are  divided  into  orders,  and  these  again  distin- 
guished according  to  the  regions,  systems,  and  organs  involved.  Thus 
the  first  class  comprises  the  four  orders — general  dwarfishness  and  gene- 
ral gigantism,  partial  gigantism  and  partial  dwarfishness  of  proportions. 
The  fourth  class  includes  the  five  orders — displacement,  preternatural 
union,  preternatural  connection,  sept-formation,  disjunction,  &c. 

Complicated  anomalies  are  classed  in  three  subdivisions. 

1.  Heterotaxies  (irepos  and  rogts).     Anomalies  important  in  an  ana- 
tomical sense,  but  neither  visible  externally  nor  obstructive  of  any  func- 
tion.   In  mankind  they  comprise  but  one  order,  namely,  lateral  inversion 
of  viscera  (inversion  splanchnique). 

2.  Hermaphroditism. 

3.  Monstrosities.     Anomalies  very  considerable  in  degree,  and  con- 
sisting in  a  faulty  anatomical  arrangement  greatly  deviating  from  the 
type  of  the  species,  externally  visible,  and  obstructive  of  one  or  more 
functions. 

These  last  are  divided  into  three  classes, — into  simple,  double,  and 
triple.  The  next  division  into  orders  is  arranged  according  to  physio- 
logical characters ;  the  subdivisions  then  following,  according  to  tribes, 
families,  and  species.  Thus,  simple  monstrosities  resolve  themselves 
into  three  orders : 

1.  Autosites,  in  which  independent,  progressive  development  is  possi- 

ble. They  are  capable  of  thriving  for  a  shorter  or  longer  period 
extra  uterum. 

2.  OmpTialo sites,  in  which  mere  passive  nutrition  is  effected  through 

the  placental  circulation.  They  are  altogether  very  imperfect, 
more  especially  in  relation  to  symmetry  of  the  two  sides  of  the 
body. 

3.  Parasites ;  shapeless  masses,  deficient  even  in  an  umbilical  cord, 

adherent  to  the  sexual  organs  of  the  mother,  and  nourished  at 
their  cost. 

The  first  order,  autosites,  is  divided  into  four  tribes :  the  first  tribe 
into  two  families ;  ectromeliens,  malformations  with  deficiency  of  the 
extremities,  with  the  varieties — phocomele,  hemimele,  ectromele;  and 
symeliens,  fusion  of  members,  with  the  varieties — syme"le,  uromMe,  sire- 
nomele.  The  second  tribe  has  the  single  family  celosomiens,  prolapsus 
of  viscera  and  imperfect  anterior  closure,  anterior  fissure,  eventeration, 
with  the  varieties — aspalasome,  agenosome,  cyllosome,  schistosome,  pleu- 
rosome,  celosome.  The  third  tribe  embraces  the  three  families :  exence- 
phaliens,  imperfect  brain,  extra  cranium ;  pseudoencephaliens,  slender 
rudiments  of  brain,  with  deficiency  of  a  large  proportion  of  the  skull ; 


28  INTRODUCTION. 

and  anencephatiens,  complete  absence  of  the  brain  and  skull,  with  their 
varieties.  The  fourth  tribe  resolves  itself  into  families :  cyclocephaliens, 
arrested  formation  and  fusion  of  nose,  eyes,  and  upper  jaw ;  and  otoce- 
phaliens,  approximation  and  blending  of  the  ears,  with  arrested  develop- 
ment of  the  base  of  the  skull  and  brain,  and  concurrent  malformation  of 
the  apparatus  of  mastication — with  their  varieties. 

The  second  order,  omphalosites,  has  two  tribes,  with  three  families 
and  their  varieties.  The  first  tribe  comprises  the  two  families,  para- 
cephaliens,  rudimental  head  formation,  asymmetria  and  absence  of 
extremities  and  of  many  vegetative  organs ;  and  acephaliens,  complete 
absence  of  head,  with  its  varieties.  The  second  tribe  has  the  single 
family  of  anidiens,  reduction  of  the  entire  organism  to  a  raembrana- 
ceous  sac,  enclosing  various  soft  formations  and  sundry  bloodvessel 
ramifications. 

The  third  order,  parasites,  has  the  one  family  zoomyliens,  rudimental 
embryo  in  the  abdomen,  in  the  genitals,  &c.,  with  a  kind  of  zoomyle. 

Double  monstrosities  are  of  two  orders. 

1.  Double  autositic  monstrosities — fusion  of  two  autosites. 

2.  Double  parasitic  monstrosities — union  of  an  autosite  with  an 

omphalosite  or  parasite. 

The  first  order  (double  autositic)  embraces  three  tribes. 

The  first  tribe  subdivides  into  two  families  :  eusomphaliens,  the  union 
of  two  nearly  perfect  organisms,  each  possessed  of  a  normal  umbilicus 
and  umbilical  cord,  with  several  varieties ;  and  monomphaliens,  the 
union  of  two  organisms  having  one  umbilicus  in  common,  also  with 
several  varieties. 

The  second  tribe  includes  the  two  families,  sycephaliens,  fusion  of 
head  and  trunk ;  and  monocephaliens,  two  trunks,  with  one  head ;  with 
their  varieties. 

The  third  tribe  contains  the  two  families,  sysomiens,  single  trunk, 
with  double  head ;  and  monosomiens,  mere  vestiges  of  duplicity  about 
the  head  ;  with  their  varieties. 

The  second  order  (double  parasitic)  comprehends  three  tribes. 

The  first  tribe  has  two  families  :  lieterotypiens^  parasite  and  autosite 
united  about  the  umbilical  region,  with  varieties ;  and  heteraliens,  with 
the  single  species,  epiconu,  parasitic  head  upon  the  vertex  (capitis)  of 
the  autosite. 

The  second  tribe  blends  the  two  families  of  polygnathiens,  imperfect 
head  implanted  in  the  maxillary  apparatus  of  the  individual ;  and  poly- 
meliens  (fteloq,  membrum),  the  parasite  consisting  solely  of  extremities 
and  adjuncts ;  with  varieties. 

The  third  tribe  has  but  one  family,  the  endocymiens,  a  parasite 
enclosed  within  the  autosite. 

The  triple  monstrosities  admit  of  the  same  distinction  as  the  double, 
namely,  into  triple  autositic  and  triple  parasitic. 

The  doctrine  of  the  two  Geoffroys,  respecting  malformation,  fre- 
quently errs  in  their  having  neglected  to  adopt  for  its  basis  the  natural 
laws  of  development.  The  system  is  even  not  devoid  of  logical  inac- 
curacies, nor  sufficiently  compendious  for  practical  use. 


INTRODUCTION.  29 

Another  well-known  German  classification  is  that  of  Gurlt.  He 
divides  malformations,  generally,  into  the  three  classes  of  malformation 
in  one  body,  or  simple  monstrosities  (monstra  simplicia  or  unicorporea) ; 
double  or  twin  monstrosities  (m.  duplicia  or  bigemina) ;  and  threefold 
or  trigeminal  monstrosities  (m.  triplicia  or  trigemina). 

The  first  class  is  divided  into  six,  and,  including  hermaphrodite  forms, 
into  seven  orders. 

1.  Malformation  from  deficiency  of  parts. 

2.  From  minuteness  of  parts. 

3.  From  preternatural  fissure. 

4.  From  non-perforation  and  from  fusion  of  parts  (atresia  and 

symphysis). 

5.  From  preternatural  form  and  site. 

6.  From  extraordinary  number  of  parts. 

7.  Hermaphrodites. 

The  second  class  has  two  subdivisions. 

I.  Double  malformations  from  coalition. 
II.  Double  malformations  from  implantation. 

The  first  subdivision  breaks  up  into  four  orders. 

1.  Coalition  without  separation  at  either  end  of  the  body. 

2.  Coalition  with  separation  at  the  upper  end. 

3.  Coalition  with  separation  at  the  lower  end. 

4.  Coalition  with  separation  at  both  ends. 

In  this  classification,  as  in  those  of  Breschet,  double  formations  are 
made  distinct  from  malformations  through  excess  of  parts. 

The  most  recent  classification  is  that  of  Otto.  It  approximates  to 
those  of  Buffon,  Blumenbach,  and  Meckel.  It  arrays  malformations  in 
three  classes. 

First  class. — Monstra  deficientia,  furnishing  three  orders. 

1.  M.  perocephala,  deficient  in  some  one  portion  of  the  head,  of 

which  there  are  seven  species. 

2.  M.  perocorma,  malformations  with  deficient  vertebral  column. 

3.  M.  peromela,  deficient  development  of  the  extremities. 

Second  class. — Monstra  abundantia.  These  are  divided  into  two 
orders. 

1.  M.  ex  duobus  coalita. 

2.  M.  luxuriantia. 

Third  class. — Monstra  sensu  strictiori  deformia.  It  resolves  itself 
into  four  orders. 

1.  M.  fissione  deformia. 

2.  M.  coalitu  singularum  partium  deformia. 

3.  M.  atresi£  deformia. 

4.  M.  morbis  manifesto  deformia. 

^  To  this  system  there  is  much  to  object :  for  example,  that  perverse 
site,  that  anomalies  with  respect  to  bloodvessels,  and  certain  herma- 


30  INTRODUCTION. 

phrodite  formations,  have  no  place  in  it ;  that  fissures  and  atresise  are 
not  admitted  as  monstra  deficientia;  that  monstra  abundantia  are 
ascribed  to  coalition,  &c. 

Lastly,  Bischoff  begins  by  showing  that  for  a  classification  of  malfor- 
mations the  anatomical  character  alone  can  be  made  available,  and  that 
the  physiological  principle  is  here  altogether  inapplicable.  Having  then 
pointed  out  the  proper  method  of  determining  the  anatomical  character 
— the  diagnosis — of  a  malformation,  he  proceeds  to  build  up  the  following 
system,  which,  generally  approximating  to  those  of  Buffon  and  Blumen- 
bach,  frequently  differs  from  both  in  detail,  whilst  by  its  rigid  adherence 
to  anatomical  principles,  it  seems  to  take  the  only  admissible  ground. 

First  class. — Malformations  deficient  in  some  essential  attribute  of 

their  kind. 
Second  class. — Malformations  possessing  more  than  pertains  to  the 

standard  of  their  kind. 
Third  class. — Malformations,  the   organization   of  which  does   not 

conform  with  the  standard  of  their  kind,  but  without  either  the 

deficiency  or  the  superfluity  just  referred  to. 

First  class. — The  causes  to  which  the  malformations,  here  under 
consideration,  are  due,  may  be  very  various.  In  many  instances  we  are 
justified  in  regarding  them  as  products*  of  imperfect  conception,  whether 
the  fault  lie  in  imperfect  formation  of  the  ovum  or  in  anomalous  quality 
of  the  semen.  At  this  day,  however,  so  much  in  this  assumption  is  still 
hypothetical  that  we  are  compelled  to  deal  with  it  cautiously,  addressing 
ourselves,  where  it  is  possible,  to  other  causes,  more  especially  to  inter- 
rupted evolution  of  an  organ  out  of  its  germ,  or  to  its  development 
being  impeded  through  external  influences,  such  as  impressions  wrought 
upon  the  mother ;  destruction  of  the  organ,  in  the  progress  of  its  deve- 
lopment, through  disease,  particularly  through  dropsical  accumulation ; 
finally,  destruction  of  an  organ  through  mechanical  influence — for 
example,  the  amputation  of  a  limb  by  means  of  the  umbilical  cord  or  a 
pseudomembranous  formation  within  the  ovum,  &c. 

This  class  comprises  the  following  orders : 

1.  Deficiencies  in  a  stricter  sense. 

2.  Malformation  from  diminutiveness  of  parts. 

3.  Malformation  from  coalition  (symphysis). 

4.  Atresiae. 

5.  Cleft-formation. 

Second  class. — Here  we  meet  with  a  regular  progression,  from  the 
supernumerary  bone  or  finger  up  to  the  development  of  two  perfect  indi- 
viduals, united  only  at  one  part.  The  series  of  this  progression  is  so 
graduated  and  so  complete,  that  Bischoff  regarded  it  as  impracticable, 
even  on  anatomical  grounds,  to  make  any  break  in  the  respective  for- 
mations, although  Breschet  and  Gurlt  have  done  this  by  distinguishing 
formations  possessing  single  supernumerary  parts  with  a  single  head 
and  trunk,  from  those  in  which  these  latter  are  twofold,  and  which  they 
denominate  twin-malformations.  This  distinction  is,  however,  based 
upon  a  physiological  principle  in  itself  objectionable.  It  is  only  to  the 


INTRODUCTION.  31 

former  species  of  malformation  that  we  assign  excess  of  plastic  vigor 
as  the  source  of  the  supernumerary  parts ;  whilst  true  twin-formations 
are  referred  to  the  fusion  or  coalition  of  double  primitive  germs,  imply- 
ing deficiency  of  plastic  vigor,  inasmuch  as  each  germ  individually 
must  be  imperfectly  developed. 

This  class  comprises  the  following  orders : 

1.  Malformations  from  superfluity  of  single  parts,  with  a  single 

head  and  trunk. 

2.  Twin  malformations  with  double  head  and  trunk. 

3.  Double  malformations  from  implantation. 

4.  Triple  malformations. 

Third  class. — Its  defect  is  that  its  characteristics  are  principally  of  a 
negative  kind. 

The  objects  comprised  in  this  class  being  very  numerous,  their  pro- 
bable sources  are  in  a  corresponding  degree  various.  For  several 
formations  no  other  cause  can  be  assigned  than  an  anomaly  of  plastic 
activity  originating  in  some  primitive  configuration  of  the  germ ;  in  a 
few  other  instances  disease  may  be  assumed  as  the  cause ;  the  majority, 
however,  will  be  explicable  on  the  ground  of  arrest  of  development. 

This  class  contains  the  following  orders : 

1.  Change  in  the  position  of  organs. 

2.  Deviations  in  the  form  of  organs. 

3.  Deviations  in  the  origin  and  the  disposition  of  the  arteries  and 

veins. 

4.  Hermaphrodites. 

As,  according  to  our  plan,  all  malformations  will  be  considered  under 
heads  corresponding  with  the  classes  and  orders  of  the  above  system, 
and  as  we  shall  also  follow  BischofF  in  our  physiological  notice  of  the 
species,  an  occasional  reference  to  this  system  will,  for  the  present, 
obviate  the  necessity  for  a  further  enumeration  of  the  species  belonging 
to  each  order. 

On  the  other  hand,  we  have  here  to- notice,  in  a  general  way,  the  laws 
which  nature  observes  in  the  production  of  malformations,  so  far  as  a 
general  working  out  of  this  subject  has  revealed  them  to  us. 

1.  The  worst  malformation  is  never  so  anomalous  as  not  to  bear  the 
general  characters  of  animal  life,  and  the  external  semblance  of  the 
particular  class  of  animals  to  which  it  belongs.     Even  an  individual 
organ  never  departs  from  its  normal  character  so  completely  that,  amid 
even  the  greatest  disfigurement,  this  character  should  not  be  cognizable. 

2.  Deviations  from  the  normal  are,  then,   confined  within    certain 
limits,  and  this  applies  in  an  especial  manner  to  anomalies  of  position. 
Although  that  which  should  lie  on  the  right  may  appear  on  the  left, 
and  the  converse — the  abdominal  organs  occupy  the  thorax,  and  the 
thoracic  the  abdomen — the  brain  has  never  yet  been  found  in  the  chest 
or  abdomen,  nor  the  kidneys  within  the  skull.     The  natural  history  of 
development  reveals  the  cause, — different   organs   and  systems  being 
developed  out  of  different  layers  of  the  germ ;  those  pertaining  to  the 
same  layer  may  indeed  err  as  to  their  locality,  but  in  no  instance  will 


32  INTRODUCTION. 

an  organ  pertaining  to  the  animal,  become  evolved  out  of  the  vegetative 
layer  of  the  germ,  nor  the  converse.  Fleischmann  calls  this  the  law  of 
localities  (lex  topicorum). 

3.  To  this  we  may  add,  that  certain  conjunctions  between  organs,  for 
example,  the  aorta  and  the  intestinal  canal  forming  a  single  tube  in 
common,  never  occur ;  but  that,  as  a  rule,  homogeneous  or  kindred  parts 
alone  unite,  a  law  termed  by  Fleischmann  the  law  of  individuality  (lex 
proprietatis). 

4.  The  excessive  development  of  one  part  determines  the  imperfect, 
retarded  development  of  another,  and  the  converse.      Meckel  having 
laid  it  down  as  the  next  thing  to  a  law,  that  a  preponderance  of  one 
organ  is  associated  with  the  retarded  growth  of  another,  Geoffroy  St. 
Hilaire   has   invested   this   law — as   the  law  of  compensation  (loi  de 
balancement) — with  the  most  ample  significance  and  extension.     The 
said  law  has  in  reality  sundry  facts  for  its  foundation ;  it  is  alleged,  in 
particular,  that  individuals  having  on  one  hand  or  one  foot  a  super- 
numerary finger  or  toe,  are  often  found  wanting  in  a  finger  or  toe  on 
the  other  foot  or  hand.     A  foetus  described  by  Neumann  had  on  the 
left  foot  only  the  great  toe,  but,  on  the  right,  eight  toes,  the  eighth 
being  cleft.     Segala's  foetus  had  no  thumb  to  the  left  hand — to  the 
right,  two ;  it  had  on  one  side  eleven  ribs  only,  but  thirteen  on  the 
other.     In  cases  where  more  or  fewer  important  parts  are  wanting  or 
imperfectly  developed,  we  often  find  supernumerary  fingers  and  toes  ;  for 
example,  in  anencephalia,  cyclopia,  spina  bifida,  hare-lip,  cleft  abdo- 
minal parietes,  &c.     In  the  siren-malformation  there  is,  according  to 
Meckel,  always  an  excessive  number  of  vertebrae  and  of  ribs.      In 
acephali,  deficient  in  heart  and  liver,  the  kidneys  are  asserted  by  Elben 
to  be  preternaturally  developed.     On  the  other  hand,  in  the  double 
formation  of   individual  parts,  others    are  frequently  imperfect:  thus, 
bitruncate  malformations   are  frequently  acephali,  whilst  the  bicepha- 
lous have  often  spina  bifida;  and  in  either  case  sundry  other  organs 
besides  have  suffered  an  arrest  of  development,  being  deficient  in  abdo- 
minal parietes,  the  intestinal  canal  being  imperfect,  the  urethra  imper- 
forate,  or  cloacal  malformation  present.     Meckel  has  even  made  this 
law  apply  to  different  children  of  the  same  parents :  one  girl  had  on 
each  hand  a  supernumerary  finger,  her  sister  had  two  fingers  wanting  to 
one  hand. 

Meckel,  rightly,  we  think,  rejects  the  assumption  of  a  law  of  compen- 
sation, where  compensation  is  so  far  from  general,  and  admits  only  that 
malformations  are  often  influenced  by  a  law  common  to  organized 
bodies. 

5.  Not  every  organ  or  part  is  in  an  equal  measure  obnoxious  to  mal- 
formation.    According  to  Meckel  it  is  far  more  rare  in  organs  supplied 
by  cerebro-spinal  nerves  (muscles,  larynx,  lungs),  than  in  those  supplied 
by  the  sympathetic  (the  digestive,  urinary,  generative).     The  vascular 
system  is,  however,  most  liable  of  all. 

6.  Certain   malformations   affect  certain   organs.      Thus,    it  is    an 
admitted  fact  that  formations  resulting  from  the   vegetative  and  the 
vascular  layer  of  the  germ  seldom  multiply,  compared  with  those  which 
result  from  the  animal  layer.     Instances  of  multiplied  heart,  lungs,  in- 


INTRODUCTION.  33 

testinal  canal,  uropoietic  and  generative  organs,  are  far  more  rare  than 
of  multiplied  head,  organs  of  sense,  extremities,  &c. 

7.  Whilst  certain  malformations  are  about  equally  frequent  in  both 
halves  of  the  body,  certain  others   affect  by  preference  the  one  or  the 
other  side  of  the  upper  or  the  nether  half  of  the  body.     Where  the 
vertebral   artery  originates  immediately  from  the  aorta,  "this,"    ob- 
serves  Meckel,   "  happens  invariably  on  the  left  side."     Cleft  lip  and 
cleft  palate  are  commonly  found  on  the  right  side.     Malformations  from 
superfluity  are  much  more  frequent  in  the  upper  than  in  the  nether  half 
of  the  body.     Thus,  bicephalous  monsters  with  a  single  trunk  are  more 
frequent  than  rnonocephalous  with  double  trunk ;  supernumerary  fingers 
than  supernumerary  toes.     In  like  manner,  anomalous  bloodvessels  are 
more  common  in  the  superior  extremities  than  in  the  inferior. 

8.  Female  malformations  are,  by  all  accounts,  much  more  frequent 
than  male.     A  reason  for  this  cannot  at  present  be  assigned. 

Of  the  hereditary  nature  of  malformations,  and  their  repetition  in 
children  of  the  same  parents,  Meckel  has  collected  numerous  examples. 
The  entail  is  transmitted  equally  through  the  male  and  through  the 
female  line.  Meckel  adduces  an  instance  of  a  man  with  six  fingers  to 
each  hand  and  six  toes  to  each  foot  transmitting  the  same  malformation 
to  his  eldest  son,  whose  three  sons  again  were  born  with  precisely  the 
same  redundant  organization. 

Various  and  manifold  as  are  the  forms  of  monstrosity,  some  of  them 
recur  with  such  uniformity  of  type,  as  to  constitute  a  regular  series. 
This  applies  to  every  organ,  each  being  especially  liable  to  some  parti- 
cular kind  of  malformation.  This  circumstance  is  of  great  importance  in 
summing  up  the  causes  of  malformations.  It  indicates  that,  in  the 
majority,  not  an  extrinsic,  accidental  cause  prevails,  but  an  intrinsic  one, 
inherent  in  the  laws  of  germination  and  development. 

With  the  aforesaid  laws,  derived  more  immediately  from  malforma- 
tions, a  mistaken  attempt  has  been  made  to  couple  two  other  special 
laws: 

1.  The  first  being  that  of  Serres,  according  to  whom  the  development 
of  an  organ  altogether  depends  upon  the  development  of  the  blood- 
vessels, and  especially  of  the  arteries.     Conformably  herewith,  imperfect 
development,  or  the  absence,  or  again  the  excess  of  an  organ  or  part, 
would  be  a  consequence  of  the  insufficiency,  or  the  absence,  or  again  of 
the  preternatural  development  of  the  supplying  artery.     But  even  were 
the  fact  altogether  true,  the  cause  of  the  defective  or  excessive  develop- 
ment of  the  artery  would  still  remain  to  be  accounted  for.     The  rela- 
tion, therefore,  not  of  dependence,  but  merely  of  correspondence  between 
the  degree  of  development  of  the  malformed  organ  and  of  its  supplying 
vessels,  would  be  proved,  as  the  rule,  and  even  this  subject  to  occasional 
exceptions.     Bischoff,  however,  regards  as  decisive  the  direct  observa- 
tion that,  in  their  rudiments,  organs  are  immediately  evolved  out  of  the 
germ,  previously  to  their  being  furnished  from  bloodvessels ;  the  consti- 
tuting cells  subsequently  becoming  metamorphosed  in  such  wise,  that, 
out  of  one  portion  bloodvessels  and  blood,  out  of  another  the  other 
(secondary)  elements  of  the  organ  are  derived. 

2.  According  to  the  second  law,  the  nerves  are  substituted  for  the 

VOL.  I.  3 


34  INTRODUCTION. 

bloodvessels,  as  the  media  of  development.  Tiedemann  has  shown  that, 
with  the  absence  of  certain  nerves  is  coupled  the  absence  of  their  depen- 
dent organs ;  that  in  all  monstrosities  with  excess,  a  corresponding  rela- 
tion is  demonstrable  in  the  nervous  system ;  and,  again,  that  in  malfor- 
mations with  coalition  of  organs,  the  fashion  of  this  union  is  exactly 
imitated  by  the  supporting  nerves.  On  the  other  hand,  the  natural 
history  of  development  has  shown  that  the  central  parts  of  the  nervous 
system  constitute  the  first  vestiges  of  the  embryo,  being  thrown  oftt 
cognizably  as  such  by  the  germ.  Upon  such  grounds,  the  opinion  has 
been  formed  that,  like  the  normal,  so  also  the  anomalous  development 
of  the  different  organs  of  the  embryo  is  dependent  upon  the  normal  or 
anomalous  development  of  the  nervous  system.  Against  this  view  the 
objection  hinted  at  in  the  last  paragraph  might  again  apply. 

XVIII.  The  disposition  to  different  diseases  varies  according  to  age, 
sex,  climate,  &c. 

Thus,  aneurism  belongs  chiefly  to  manhood  and  advanced  age,  rickets 
exclusively  to  childhood ;  the  foetus  labors  under  anomalies  proper  to 
primary  development  alone — namely,  malformations.  In  childhood 
tuberculosis  attacks,  preferably  to  all  other  parts,  the  lymphatic  glands, 
the  brain ;  at  and  beyond  the  age  of  puberty,  the  lungs.  The  female 
sex  greatly  favors  the  occurrence,  in  the  sexual  system,  of  cystoids,  of 
cystosarcoma,  of  the  majority  of  carfcerous  growths.  Under  certain 
climatic  relations,  tuberculosis  is  rare, — intermittent  fever,  hypertrophy 
of  the  spleen,  frequent ;  under  the  tropics  the  ossification  of  arteries  is 
said  to  be  extremely  rare.  Again,  particular  regions  and  parts  of  the 
body  manifest  different  dispositions  with  respect  to  the  frequency  of  con- 
genital or  acquired  anomalies.  Thus,  Portal  pronounces  apoplexy  to  be 
more  frequent  in  the  right  corpus  striatum  than  in  the  left, — pneumonia 
is  more  common  in  the  right  lung  than  in  the  left.  The  arteries  of  the 
inferior  extremities  are  infinitely  more  obnoxious  than  those  of  the 
superior  to  ossification  and  to  spontaneous  aneurism ;  the  veins  of  the 
lower  half  of  the  body  are  almost  exclusively  subject  to  varix.  Malfor- 
mation from  excess  appears  more  frequent  in  the  upper  half  of  the  body, 
malformation  from  coalition  more  frequent  in  the  lower  half;  variations 
in  the  course  of  bloodvessels  are  more  rare  in  the  inferior  extremities 
than  in  the  superior. 


PATHOLOGICAL  ANATOMY, 


CHAPTER  I. 

ANOMALIES  IN  RESPECT  OF  THE  NUMBER  OF  PARTS. 

THESE  consist  in  diminution  or  augmentation  of  the  normal  number 
of  organic  parts.  It  is  not  rare  for  both  to  be  found  united  in  one  indi- 
vidual, one  part  presenting  a  deficiency,  another,  in  virtue  of  the  law  of 
compensation,  an  excess  of  formation.  Thus,  monstrosities,  in  which 
otherwise  deficiency  predominates,  will  exhibit  a  superfluous  finger  or 
toe  ;  double  twin  malformations,  on  the  contrary,  deficiency  in  various 
parts. 

Deficiency  or  absence  of  individual  parts,  or  diminished  number  of 
plural  organs,  are  frequent, — for  example,  the  absence  of  entire  extre- 
mities, of  individual  fingers  and  toes  ;  amongst  the  viscera,  of  one  of  the 
kidneys.  It  is  either  congenital  or  acquired.  In  the  former  case  it  in- 
cludes malformations  with  deficiency,  in  a  stricter  sense.  There  is 
scarcely  any  part  that  has  not  been  found  wanting,  without  detriment 
to  the  entirety  of  the  rest  of  the  body.  In  this  respect,  however,  certain 
relations  or  sympathy  may  not  be  overlooked,  by  virtue  of  which  the 
absence  of  one  part  is  paired  with  that  of  another  part.  Thus,  in 
acephali  the  heart  is  almost  always  absent,  very  commonly,  too,  the 
entire  thoracic  viscera,  together  with  the  liver,  the  spleen,  the  pancreas, 
— an  example  of  compliance  with  rule  perfectly  inexplicable ;  for  neither 
can  development  from  an  identical  germ,  nor  functional  dependence  of 
the  organs  here  be  argued.  Occasionally  so  many  parts  are  absent  at 
once,  that  nothing  is  born  save  a  head,  a  single  extremity,  or  a  shape- 
less mass.  The  absence  of  parts  is  very  often,  though  by  no  means  inva- 
riably, due  to  arrest  of  development. 

The  principal  kinds  of  malformation  that  pertain  hither  are  the  fol- 
lowing (Geoffroy  St.  Hilaire,  Gurlt,  Bischoff) : 

~  1.  Amorphus,  anideus.  A  shapeless  mass  consisting  of  cutis,  areolar 
tissue,  fat,  and  a  few  bones  ;  is  never  found  but  in  association  with  a 
perfect  twin.  It  probably  results  from  an  early  destruction  of  the 
germ. 

2.  AcepTialus.  The  head  alone  may  be  wanting,  or  with  it  more  or 
less  of  the  trunk,  so  that,  in  fact,  nothing  may  be  present  save  a  pelvis 
with  the  inferior  extremities,  or  with  one  of  these  only.  It  is  for  the 
most  part  associated  with  a  twin.  Even  though  the  trunk  be  present, 


36  ANOMALIES    IN    RESPECT    OF 

the  heart  is  usually  absent ;  the  respiratory  organs  probably  always ; 
liver,  spleen,  and  pancreas  commonly ;  stomach  and  intestinal  canal  are 
generally  very  defective;  the  uropoietic  and  generative  organs  are 
mostly  present,  though  incomplete.  It  is  in  some  instances  perhaps  de- 
ducible  from  injury  to  or  destruction  of  the  germ,  or  from  the  distur- 
bance occasioned  by  a  twin. 

3.  Pseudacephalus,  paracephalus.     Rudiment  of  head,  with  the  rest 
of  the  body  either  entire  or  defective.     These  are  sometimes  twin  cases, 
and  are  for  the  most  part  the  consequence  of  hydrocephalus. 

4.  Aprosopm.     The  face,  and  especially  the  eyes,  nose,  and  mouth, 
wanting.     The  skull  is  diminutive,  and  exhibits  the   ears  coalescing, 
either  in  front  or  above.     The  brain  is  always  very  defective.     The 
pharynx  terminates,  superiorly,  in  a  caecal  sac.     Here  again,  probably, 
destruction — splitting  of  the  medullary  tube,  as  also  of  the  dorsal  plates, 
at  their  anterior  part,  takes  place  at  an  early  period.     Hence  the  non- 
development  of  the  anterior  brain-cell  with  eyes  and  nose,  and  in  like 
manner  the  superior  arches  of  the  cranial  vertebrae,  of  the  parietal  and 
of  the  frontal  vertebrae,  and  the  consequent  inclining  towards  each  other 
of  the  temporal  bones  for  the  closure  of  the  vertebrae.     Hence,  probably, 
also,  the  non-development  of   the  anterior  visceral   arches,   involving 
absence  of  the  inferior  maxilla  and  of  the  facial  bones,  with  anterior 
junction  of  the  external  ears,  which  emanate  from  the  second  and  third 
visceral  arches. 

5.  Microcephalus.      Diminutive,  incomplete  head ;    similar    to    the 
foregoing,  except  that  the  inferior  jaw  is  present,  proving  the  develop- 
ment of  the  first  visceral  arch. 

6.  Anoplithalmus.     Absence  of  both  eyes  or  of  one  eye  only.     Eye- 
lids  and  lachrymal    organs  are    present,   although  often    defective— 
coalescent.      Perhaps   for  the   most   part   dependent   upon    dropsical 
destruction  of  the  eye-vesicles,  rudiments  of  the  optic  nerves  being  com- 
monly discoverable. 

7.  Absence  of  the  eyelids  ;  an  arrest  of  formation,  these  organs  being 
of  later  development. 

8.  Absence  of  iris  ;  in  like  manner,  an  arrest  of  formation. 

9.  Anotus.     Absence  of  the  external  ear, — deficient  development  of 
the  external  portion  of  the  first  visceral  groove. 

10.  Bracliyrhynclms.     Shortness  of  nasal  prominence,  owing  to  de- 
ficiency of  intermedial  jawbones. 

11.  Acormus.     One  rudimental  head  with  a  regular  twin,  or  with  a 
triple  birth.     Most  probably  due  to  mechanical  hindrance  to  develop- 
ment, and  to  destruction  occasioned  by  the  other  foetus  or  foetuses. 

12.  Oligospondylus.     Absence  of   vertebrae  or  of  semi-vertebrae,  is 
owing  either  to  an  anomaly  of  original  germinal  development,  or  else  to 
the  coalescing  of  two  or  more  vertebrae  or  semi-vertebrae. 

13.  Anaedceus.     Absence  of  the  entire  generative  apparatus,  or  of 
the  external  organs  of  generation  only ;  very  rare  as  an  independent 
malformation,  where  the  individual  is  otherwise  normally  formed.     It 
is  an  arrest  of  development,  the  said  parts  not  being  evolved  out  of 
the  germ. 

14.  Peromelus  and  micromelus.     The  limbs  are  wanting  or  maimed. 


THE    NUMBER    OF    PARTS.  37 

It  is  frequently  an  arrest  of  development;  it  may,  however,  result 
from  mechanical  influence, — from  the  severing  of  members  through 
strangulation. 

15.  Phocomclus.      Monstrosity  with  phocal  extremities,  the  hands 
issuing  directly  from  the  shoulders,  the  feet  from  the  pelvis,  whilst  the 
intervening  parts  are  either  wanting  or  merely  rudi mental.     It  is  an 
arrest  of  development  often  dependent  upon  hydrocephalus  or  spina 
bifida. 

16.  Parosomus.     Various  deformities  caused  by  the  absence  of  in- 
dividual parts. 

17.  Absence  of  various  individual  organs  of  the  thorax  or  abdomen, 
of  a  lung,  the  liver,  the  spleen,  the  stomach  or  its  blind  sac,  a  portion 
of  intestine,  &c.     It  is  either  an  arrest  of  development  or  the  result  of 
morbid  destruction. 

A  particular  kind  of  diminution  of  number  consists  in  the  symphysis 
or  fusion  of  kindred  formations :  fusion  of  two  fingers,  toes,  ribs, 
vertebrae,  of  the  inferior  extremities,  of  the  kidneys,  obliteration  of 
the  uterus.  A  deficiency  of  various  grades  is  included  under  cleft- 
formations. 

The  acquired  absence  of  particular  parts  is  the  result  of  mechanical 
influence  or  of  disorganization.  To  the  former  kind  belongs  maiming 
by  accident  or  design ;  for  example,  amputation,  extirpation,  and  the 
like,  which  sometimes  greatly  resemble  certain  congenital  defects.  To 
the  latter  kind  is  to  be  referred  the  wasting  of  various  organs ;  for  in- 
stance, from  spontaneous,  primitive  atrophy,  from  that  consequent  upon 
inflammation,  from  destructive  suppuration  or  gangrene. 

Preternaturally  augmented  number  of  parts  is  very  frequent,  and 
commonly  congenital.  It  occurs  in  every  variety  of  grade,  from  the 
duplication  of  individual  diminutive  parts  to  that  of  the  body  almost  in 
its  totality.  These  various  degrees  constitute  a  series,  the  gradations 
of  which  are  so  regular,  that  it  would  appear  forced  to  divide  malforma- 
tions of  this  class  into  such  as  with  a  single  head  and  trunk  present  du- 
plicates of  individual  parts,  and  into  such  as  at  the  same  time  possess 
double  or  triple  head  and  trunk.  Nor  does  such  a  distinction  derive 
much  support  from  the  assumption  that  the  former  are  due  to  an  excess 
of  plastic  activity,  the  latter  to  the  primordial  existence  and  the  fusion 
of  twofold  germs. 

Bischoff(with  Winslow,  Haller,  Meckel)  opposes  the  following  weighty 
arguments  to  this  distinction,  as  also  to  the  assumption  of  twofold  germs 
and  their  fusion  (Lemery,  Breschet,  Gurlt,  Chaussier,  and  Adelon). 

1.  The  malformations  of  this  class,  from  the  supernumerary  finger  or 
toe  up  to  the  development  of  two  perfect  embryos  united  only  at  one 
point,  constitute  so  complete  and  uninterrupted  a  series,  that  it  would 
be  in  the  highest  degree  forced  to  assign  for  the  one  and  for  the  other 
opposite  causes,  namely,  excess  of  formative  activity,  and  again  fusion 
with  deficiency  of  plastic  power.     Still  no  one  can  hold  a  supernumerary 
finger  or  toe  to  be  due  to  the  fusion  of  two  embryos. 

2.  In  twin  malformations,  none  but  the  same  organs,  systems,  or  parts, 
whether  internal  or  external,  ever  coalesce.     It  is  invariably  thorax  with 
thorax,  abdomen  with  abdomen,  head  with  head,  breech  with  breech. 


38  ANOMALIES    IN    RESPECT    OF 

Again,  brain  is  ever  found  coherent  with  brain,  bloodvessels  with  blood- 
vessels, intestine  with  intestine,  &c. ;  never  trachea  with  oesophagus, 
nerves  with  bloodvessels,  and  the  like.  This  is  a  fact,  the  constancy  of 
which  precludes  its  explanation  on  the  ground  of  accidental  fusion  from 
external  causes. 

3.  Twin  malformations  manifest,  for  the   most  part,  a  change  not 
limited  to  the  parts  immediately  united,  but  pervading  the  entire  or- 
ganism.    Such  a  change  could  hardly  be  brought  about  by  accidental 
fusion. 

4.  Twin  malformations  always  recur  with  great  uniformity  of  cha- 
racter.    Are  external  causes  likely  always  to  combine  after  the  same 
fashion  ? 

5.  Again,  twin  malformations  often  occur  out  of  the  same  mother, 
and  the  tendency  to  them  is  hereditary.     There  is  neither  proof  nor 
probability  of  an  abiding  external  cause, — for  instance,  in  the  maternal 
organs  of  generation. 

6.  At  no  period  of  development  is  a  mechanical  fusion  of  the  ova  and 
embryos  probable ;  indeed,  our  present  knowledge  respecting  the  nature 
and  earliest  development  of  the  ovum  renders  such  fusion  highly  impro- 
bable.    The  pellucid  zone  or  yelk-bag  is  in  the  highest  degree  unfitted 
for  it ;  nor  is  it  at  all  possible  to  press  two  ovula  against  each  other  in 
such  wise  as  to  occasion  the  fusion  of  tfceir  yelks,  of  their  germinal  vesi- 
cles, or  of  the  zonse  pellucidae  of  the  latter.     In  the  Fallopian  tubes  and 
the  uterus,  however  contracted,  the  ovula  undergo  no  such  risk,  even  in 
multiparous  animals,  where  they  lie  densely  grouped  together.     After 
the  embryos  have  become  developed  and  shrouded  within  their  amnia, 
their  coalition  ceases  to  be  even  conceivable.     These  membranes  would 
have  to  undergo  previous  rupture  ;  for  the  occurrence  of  twins  within  a 
single  amnion  is  too  rare  and  too  inexplicable  to  be  here  taken  into 
account.      How  slight  is  the  disposition  amongst  various  embryos  to 
coalesce  is  shown  by  those  cases  of  twins,  in  which,  owing  to  confined 
space,  the  one  is  almost  flattened  by  compression,  without  any  coalition 
having  taken  place. 

It  results  from  the  above  that  the  aforesaid  division  of  malformations 
with  supernumerary  parts,  and  the  assumption  of  twofold  germs  and 
their  coalition,  are  inadmissible.  The  task,  therefore,  still  devolves 
upon  us  of  explaining  this  class  of  malformations.  Accordingly  we 
have  to  observe  that : 

1.  The  cause  might  consist  in  an  anomalous  formation  of  the  ovum  in 
its  unimpregnated  state.      Bischoff  adduces  in  favor  of  this  view  the 
occurrence  of  double  yelks,  as  also  the  aforesaid  hereditary  character  of 
twin  formations  and  their  recurrence  out  of  the  same  mother.     This 
cause  would,  however,  apply  only  to  more  perfect  twin  formations,  it 
being  difficult  to  imagine  a  mere  supernumerary  finger  or  even  extremity 
to  have  a  similar  origin. 

2.  Some  have  long  conceived  the  formative  power  within  the  germ  to  be 
endowed  with  unusual  energy,  causing  the  development  of  a  greater 
number  of  parts  than  belong  to  the  species.     The  facts  observed  by 
Wolff,  Von  Bar,  and  Reichert,  certainly  relate  to  twin  formations  of 
a  very  early  stage  of  development.     Still  this  stage  is  too  far  advanced 


THE    NUMBER    OF    PARTS.  39 

to  be  cited  in  direct  support  of  an  assumed  augmentation  of  plastic 
power  in  the  germ,  as  determining  either  an  approach  to  the  formation, 
out  of  the  plastic  materials  of  the  yelk,  of  a  double,  or  even  of  the  par- 
tition of  a  single  zona  pellucida.  On  the  other  hand,  these  cases  are  of 
a  period  so  early,  and  of  characters  so  marked,  as  to  render  it  almost 
self-evident  that  the  cause  of  the  malformation  must  have  been  a  pri- 
mordial one,  or  at  least  have  dated  from  the  earliest  period.  The  mul- 
tiplication of  individual  parts  is  possible  at  a  later  period,  provided  the 
germ  remain  for  them  unchanged. 

3.  One  species  of  twin  formations  can  at  the  present  time  only  be 
satisfactorily  explained  by  the  assumption  of  an  ovum  in  ovo, — one 
ovum  being  primitively  enclosed  within  another.     We  refer  to  twin 
formations  from  invagination  or  implantation,  so-termed  conceptionlike 
germination  (Meckel) — diplogdnese  par  penetration.    One  foetus  incloses, 
at  some  part,  another  imperfect  foetus — a  foetus  in  fcetu :  or  else  one 
foetus  is  at  some  one  point,  commonly  at  the  skull  or  palate,  united  with 
another  foetus,  through  the  medium  of  a  more  or  less  perfect  umbilical 
cord.     Meckel  regarded  the  foetus  in  foetu  as  a  product  of  conception, 
and  sought  to  maintain  this  view  by  an  appeal  to  analogy ;  adducing, 
for  example,  the  formation  of  hair  and  teeth  independently  of  copula- 
tion,   sexless   multiplication   and   propagation,  regeneration.      At   the 
present  day  monosexual  conception  is  hardly — multiplication  by  cotyle- 
dons or  offshoots,  in  nowise — admissible.     Certain  of  the  observations 
in  point  relate  to  cases  of  malformation  in  the  early  embryo,  in  the  third 
and  seventh  month,  for  example,  in  which  a  conceptionlike  product  is 
simply  impossible.     The  occurrence  of  ovum  in  ovo,  in  the  instance  of 
birds,  at  least,  is  proved ;  the  intussusception  of  one  ovum  into  another 
during  development  is,  on  the  other  hand,  not  conceivable. 

4.  Finally,  an  augmented  number  of  parts  depends  not  unfrequently 
upon  arrest  of  development,  and  the  anatomical  excess  is  reduced  to  one 
of  no  real  physiological  import ;  for  example,  the  true  diverticulum  of 
the  intestine  as  the  remnant  of  the  omphalo-mesenteric  duct,  double 
frontal  bones,  and  the  like. 

Malformations,  with  supernumerary  parts,  are  divisible  into  several 
orders,  which,  with  their  principal  species,  are  as  follows : 

1st   order. — Malformations   with   individual   parts  supernumerary — 
head  and  trunk  being  single. 

Dignathus.     Malformation  with  supernumerary  lower  jaw. 
Caudatus.     Human  foetus  with  tail-like  process  at  the  os  sacrum. 
Polydactylus.     Malformation  with  supernumerary  fingers. 
Notomeles.     Monstrosity  having  supernumerary  limbs  at  the  back. 
Pygomeles,     Having  supernumerary  limbs  at  the  os  sacrum. 
G-astromeles.     With  supernumerary  limbs  at  the  normal  extremities. 
To  which  are  to  be  added : 

1.  Supernumerary  skull  bones. 

2.  "  vertebrae. 

3.  "  ribs. 

4.  "  muscles. 

5.  "  teeth. 


40  ANOMALIES    IN    RESPECT    OF 

6.  Double  tongue  (always  superimposed). 

7.  Double  oesophagus. 

8.  True  diverticulum  of  intestine. 

9.  Double  caecum  and  vermiform  process. 

10.  Double  pancreatic  duct. 

11.  Double  hepatic  duct. 

12.  Manifold  spleen. 

13.  Double  heart. 

34.  Multiplicity  of  kidneys,  probably  due  to  arrest  of  development. 

5.  Double  or  triple  ureters. 

16.  Double  bladder. 

17.  Triple  testicle  (?). 

18.  Double  penis  and  clitoris  (?). 

19.  Double  uterus  (U.  duplex,  bicornis,  bilocularis) ;    to  be  re- 

garded altogether  as  arrest  of  development. 

20.  Testicles  and  ovaries,   seminal  ducts,   seminal  vesicles,  Fal- 

lopian tubes,  uterus,  &c.,  in  the  same  individual. 

21.  Supernumerary  mammae. 

2d  order. — Twin  monstrosities,  with  double  head  and  trunk. 

(a.)  Double  formation  of  the  upper  portions  of  the  body. 

Heteroprosopus.  Two  countenances^;  the  one  perfect,  the  other  im- 
perfect. 

Dicranus.  Double  skull ;  countenance  either  single,  or  double  and 
conjoined ;  lower  jaw  single. 

Monocranus.  Single  skull;  countenance  partially  double;  brain 
double,  but  unequally  so ;  three  or  four  eyes. 

Diprosopus.  Double  countenance;  the  faces  and  heads  are  com- 
pletely separate,  or  the  separation  affects  the  faces  to  the  zygomatic 
arches  only ;  lower  jaw  invariably  double. 

Dicephalus.  Two  entirely  separate  heads,  with  two  (seldom  three) 
upper,  and  two  (seldom  three)  lower  extremities. 

Thoraco-gastrodidymus.  Two  heads  and  necks,  thorax  and  abdomen 
united  into  one;  four  upper  and  two  or  three  lower  extremities.  (The 
Sardinian  twin  sisters.) 

G-astrodidymus.  Twins  united  at  the  lower  part  of  the  belly ;  the 
four  inferior  extremities  branch  off  from  the  sides  in  pairs,  at  right  angles. 

Pygodidymus  (Gurlt),  Pygopages  (G.  St.  Hilaire).  Two  completely 
distinct  bodies,  conjoined  at  their  ossa  sacra  or  coccygis.  [The  well- 
known  Hungarian  sisters,  Helena  and  Judith,  born  in  the  year  1701, 
who  survived  their  22d  year.] 

(5.)  Double  formation  of  the  nether  parts  of  the  body. 

Dipygus  or  Monocephalus  (Gurlt),  Thoradelphus  (G.  St.  Hilaire). 
Head,  neck,  and  thorax  single  ;  abdomina  and  posterior  parts  separate ; 
two  or  four  upper,  always  four  lower,  extremities. 

Heterodidymus  (Gurlt),  Heteradelphus  (G.  St.  Hilaire) ;  so-called 
parasite  formation.  A  large,  regularly  formed  body,  bearing,  at  the 
chest  or  belly,  another,  more  or  less  incomplete. 

Dihypogastricus ;  so-called  Janus  formation.  Double  body,  more  or 
less  coalescent  above ;  separate  from  the  umbilicus  downwards.  Here, 


THE    NUMBER    OF    PARTS.  41 

either  two  heads  are  united  with  the  two  countenances  (one  of  which  is 
commonly  defective),  presenting  in  opposite  directions ;  or  else  there  is 
but  a  single  (perhaps  defective)  countenance,  with  a  double  coalescent 
head.  The  trunk  is  double,  united  down  to  the  umbilicus,  and  has  four 
upper  and  four  lower  extremities. 

Symphysocephalus  (Barkow),  Ceplialopages  (G.  St.  Hilaire).  Twin 
monstrosity  united  at  the  head ;  the  twins  may  be  perfect,  or  of  the  one 
nothing  may  exist  except  the  head. 

(<?.)  Double  formation,  both  above  and  below. 

Diprosopus  dicedoeus  (Barkow),  Tetrascelus  (Gurlt).  Two  heads, 
united  at  the  sides ;  thorax  and  abdomen  coalescent ;  two  or  four  upper 
extremities ;  urinary  and  generative  organs,  as  also  the  inferior  extremi- 
ties, double. 

Hemipages  (G.  St.  Hil.)  The  heads  superficially  coherent  at  the 
sides ;  lower  jaw  in  common ;  neck,  thorax,  and  abdomen  as  far  down  as 
the  umbilicus,  coalescent ;  pelves  separate ;  four  upper  and  four  lower 
extremities. 

Thoracodidymus  (Gurlt).     Two  distinct  bodies  united  at  the  thorax. 

Xyphopages.  Two  perfectly  distinct  bodies,  united  only  in  the  vici- 
nity of  the  ensiform  process.  (The  well-known  Siamese  twin  brothers.) 

3d  order. — Twin  malformations  through  implantation. 

Cryptodidymus  (Gurlt) ;  so-called  foetus  in  foetu.  The  greater,  per- 
fect foetus  bears  at  some  point  beneath  the  skin,  or  within  its  natural 
cavities,  a  second,  smaller,  and  imperfect  foetus. 

OmpJialo-cranodidymus.  The  umbilical  cord,  together  with  the  rudi- 
ment of  the  one  foetus,  rooted  within  the  skull  of  the  other. 

Epignathus.  An  imperfect  foetus  rooted,  with  its  bloodvessels,  at 
the  palate  of  a  more  perfect  foetus. 

4th  order. — Triple  monstrosities.  Their  existence  is  confirmed  by 
modern  researches. 

Supernumerary  parts  may  be  normal,  both  in  form  and  structure ;  in 
both  respects,  however,  they  are  frequently  in  various  degrees  defective. 

The  frequency  of  duplicate  forms  varies  in  different  portions  of  the 
body ;  for  example,  a  multiplication  of  viscera,  or  of  organs  of  sense,  is 
far  more  rare  than  of  extremities. 

It  will  be  seen  from  the  above,  that  in  twin  monstrosities  the  con- 
nection between  two  individuals  is  either  a  mere  superficial  one,  occur- 
ring through  the  medium  of  skin  and  of  bone,  or  else  one  involving,  at 
the  point  of  union,  the  blending  of  cavities  of  the  body,  and  the  union, 
in  various  degrees,  of  the  same  organs  in  the  two  individuals. 

Acquired  preternatural  increase  of  number  consists,  in  man  and  in 
the  higher  animals,  in  a  multiplication  of  the  elementary  constituent 
parts  of  a  tissue, — of  the  essential  or  the  secondary  structural  elements 
which  enter  into  the  composition  of  an  organ.  It  is,  therefore,  the 
manifestation  of  increase  of  mass  or  density  in  an  organ — never  of  the 
development  of  new,  complex  ones.  Still,  the  arrest  or  alienation  of 
tissues  developed  for  the  repair  of  injuries,  or  of  destructive  morbid  pro- 
cesses, does  sometimes  determine  the  formation  of  supernumerary  appa- 
ratuses foreign  to  the  standard  of  the  organism ;  for  example,  anomalous 
excretory  ducts ;  accessory  articulations. 


42  ANOMALIES    OF    SIZE. 

CHAPTER  II. 

ANOMALIES  OF  SIZE. 

ANOMALIES  of  volume  manifest  themselves  as  irregularities  in  magni- 
tude, and  as  their  opposite,  diminutiveness,  both  being  either  congenital 
or  acquired.  They  are  often  relative  only,  that  is,  applicable  to  one 
period  of  development  or  of  life.  Again,  their  significance  and  import 
may  be  limited  to  the  proportions  of  the  organ  concerned,  as  in  small- 
ness  of  the  brain  ;  in  enlargement  of  the  heart.  Finally,  they  refer, 
either  uniformly  or  unequally,  to  the  entire  body  or  to  individual  organs. 

ABNORMAL    MAGNITUDE. 

Congenital  abnormal  magnitude  is  sometimes  general.  In  relation  to 
the  entire  body  it  is  termed  gigantic  growth — macrosomia.  Some  chil- 
dren are  born  inordinately  large  and  powerful,  and  endowed  with  other 
marks  of  precocious  development  besides ;  for  instance,  closure  of  the 
sutures,  unusual  strength  and  length  of  hair,  extrusion  of  one  or  more 
teeth.  Others,  impelled  by  innate  predisposition,  undergo  preternatural 
growth  during  youth,  and  eventually  arrive  at  dimensions  exceeding  the 
ordinary  standard — in  a  word,  grow  up  giants.  Giant  stature  may  de- 
pend upon  the  equal  and  proportioned  lengthening  of  all  the  parts,  or 
upon  the  predominant  length  of  certain  sections  of  the  body,  especially 
of  the  lower  extremities.  Giant  stature  does  not  needs  imply  corre- 
sponding development  of  the  substance  of  organs  and  parts,  certain  of 
which  may  possibly  have  been  checked  in  their  growth ;  for  example, 
the  muscular  system,  the  heart,  the  brain,  the  adipose  tissue,  the  organs 
of  generation. 

Preternatural  dimensions  of  individual  organs  of  the  body,  both  con- 
genital and  acquired,  are  of  far  more  frequent  occurrence.  These  origi- 
nate in  a  primary  anomaly  or  in  excessive  plastic  activity  of  the  germ, 
or,  again,  in  hypertrophy,  or  in  the  dilatation  of  hollow  organs,  or, 
lastly,  in  a  variety  of  diseases  in  which  the  textures  of  organs  become 
involved  at  different  periods  of  intra-  and  of  extra-uterine  life.  These 
last  consist  for  the  most  part,  in  hyperaemia,  inflammation,  and  all  kinds 
of  heterologous  formations.  Congenital  enlargement  sometimes  imports 
arrest  of  development,  as,  for  example,  a  preternaturally  large  thymus 
gland. 

Hypertrophy  and  the  dilatation  of  hollow  organs  require  to  be  con- 
sidered somewhat  more  at  large. 

HYPERTROPHY. 

Hypertrophy  consists,  as  the  term  implies,  in  augmented  nutrition, 
resulting  in  increase  of  mass,  and  generally  also  of  volume.  Long  ere 
the  term  hypertrophy,  and  even  the  idea  it  conveys,  were  formally  re- 
cognized in  science,  not  only  had  the  possibility  of  an  increase  of  mass 


ANOMALIES    OF    SIZE.  4d 

and  volume  without  material  destruction  of  texture  been  speculated 
upon,  but  the  fact  itself  actually  observed  in  every  variety  of  organ. 
Even  up  to  the  present  time,  however,  the  recognition  of  this  species  of 
anomaly  has  been  characterized  by  a  great  want  of  clearness  and  pre- 
cision. It  is  reserved  for  the  discrimination  of  the  present  generation, 
by  a  searching  comparative  inquiry,  based  upon  a  more  familiar  ac- 
quaintance with  the  normal  relations  of  the  structure  and  admixture  of 
organs,  and  aided  by  the  physical  appliances  now  at  our  command,  to 
make  an  important  progressive  step  over  this  wide  and  fertile  field. 

1.  Simple  augmented  nutrition,  the  increment  of  mass  and  of  volume, 
not  dependent  upon  the  accession  of  any  element  foreign  to  the  organ 
concerned — TRUE  HYPERTROPHY. 

2.  Anomalous  augmented  nutrition.     The  increase  of  mass  and  of 
volume  is  here  founded  upon  the  accession  of  matter  alien  to  the  organ 
concerned,  be  it  formless  blastema  or  determinate  form-element.     This 
anomalous  matter,  when  uniformly  incorporated  with  the  texture  of  the 
organ,  that  is,  received  both  betwixt  and  within  the  definite  structural 
elements,  manifests  itself  as  infiltration  of  the  parenchyma — FALSE  HY- 
PERTROPHY.    It  approximates  closely  to  heterologous  growth. 

Such  are  the  two  sections  into  which,  as  a  preliminary  step,  we  would 
distinguish  all  the  so-called  hypertrophies.  Each  will,  however,  have  to 
be  specially  considered  in  the  sequel. 

Widely  as  the  two  hypertrophies  should  appear  to  differ  from  each 
other,  and  little  as,  strictly  speaking,  the  second  series  belongs  hither, 
its  consideration  in  this  place  will  be  found  preferable  as  regards  practi- 
cal utility,  and  expedient  for  other  weighty  reasons. 

(a.)  From  true  hypertrophy  to  false  there  are  insensible  gradations, 
both  qualitative  and  quantitative,  and  both  forms  may  coexist  in  the 
same  organ.  Thus,  augmentation  of  the  fatty  contents  of  the  hepatic 
cells  is,  by  the  addition  of  free  fat  and  by  a  change  in  the  quality  of  the 
fat,  exalted  into  a  palpable  heterologous  process. 

(6.)  Between  the  two  series  there  exists  the  common  connecting  link 
that  both  are  based  upon  an  anomaly  of  the  crasis ;  that,  provided  no 
obvious  local  causes  prevail,  both  are  engendered  by  a  peculiar,  personal, 
more  or  less  defined,  morbid  tendency  of  general  nutrition. 

Every  organ  is  by  nature  susceptible  of,  and  almost  every  one  has 
with  more  or  less  of  precision  been  described  as  actually  found  affected 
with,  hypertrophy.  This  does  not,  however,  now  apply  equally  to  both 
categories  of  hypertrophy — that  of  the  areolar  and  of  adipose  tissues, 
and  of  the  muscles,  more  especially  the  organic,  commonly  manifesting 
itself  as  true,  that  of  the  so-called  parenchymatous  organs  still  more 
commonly  as  false  hypertrophy. 

(a.)  True  hypertrophy. 

True  hypertrophy  appears,  a  priori,  incontestable,  and  numberless  in- 
stances have  been  recorded  of  its  occurrence  in  every  part  of  the  body. 
It  is  remarkable,  however,  that  when  tested  by  an  analysis,  with  refer- 
ence to  elementary  texture  and  development,  the  proof  is  attended  with 
extraordinary  difficulty  as  regards  the  most  important  organs  and  tissues. 

When  it  is  the  question,  not  of  an  obvious  augmentation  of  the  less 


44  ANOMALIES    OF    SIZE. 

important  components  of  an  organ — for  example,  of  the  areolar,  the 
fibrous,  the  adipose  tissues — but  of  a  multiplication  of  the  essential  struc- 
tural elements,  the  positive  proof  by  elementary  analysis  often  fails, 
although,  both  before  and  after  death,  the  characters  of  the  organ  may 
seem  quite  sufficiently  exaggerated  to  warrant  the  assumption  of  true  hy- 
pertrophy. 

Apart  from  a  development  of  substance  resulting  from  extraordinary 
succulence  of  the  texture — that  is,  from  its  imbibing  an  excess  of  amor- 
phous plasma  more  or  less  rich  in  nutrimental  substances — hypertrophy 
can  only  depend  either  upon  a  multiplication  of  the  essential  textural 
elements  by  an  accession  of  new  ones,  or  else  upon  an  enlargement  of 
the  original  ones.  Upon  this  point  a  generalization  is  not  feasible  at 
the  present  day,  and  it  must  suffice  to  set  forth  in  due  succession  the  re- 
sults of  researches  touching  special  hypertrophies. 

We  may  specify,  as  unquestionable,  hypertrophy  of  the  areolar,  of  the 
fibrous,  and  of  the  adipose  tissues ;  of  the  common  integuments,  includ- 
ing, not  alone  the  cutis  and  the  papillary  bodies,  but  also  the  sebaceous 
glands  and  the  epidermidal  formations ;  of  the  mucous  membranes  and 
their  follicles ;  and  lastly,  of  the  bones. 

Hypertrophy  cannot  indeed  be  demonstrated  by  a  comparative  enume- 
ration of  the  form-elements;  and  the  size  of  the  latter  varies  considera- 
bly even  in  the  physiological  state.  <  Where,  however,  the  increase  of 
mass  is  obvious,  and  there  is  no  accession  of  heterogeneous  elements, 
the  sum  of  the  primitive  form-elements  must  needs  have  become  multi- 
plied, and  hypertrophy  exist.  We  find,  too,  in  the  involved  textures — 
for  example,  in  areolar  tissue — an  extraordinary  number  of  the  elements 
in  their  embryonic  stages. 

Hypertrophy  of  muscle,  however  simple  it  may  seem,  is  in  reality 
most  difficult  of  proof.  The  increase  of  mass  and  volume  in  a  hyper- 
trophied  muscle  certainly  seems  due  to  augmentation  of  its  amount  of 
fleshy  fibres ;  positive  evidence,  however,  at  least  with  respect  to  the  stri- 
ated muscles,  has  hitherto  been  wanting.  An  enumeration  of  the  primi- 
tive fibres  is  not  feasible,  nor  have  elements  obviously  engaged  in  the 
embryonic  phases  of  new  muscle-formation  been  as  yet  detected.  Still 
less  has  an  enlargement  of  the  primitive  muscular  fibres,  through  increase 
in  the  amount  of  their  primitive  fibrils,  been  made  out.  That  the  hyper- 
trophy consists  simply  in  the  augmented  growth  of  the  myolemma  is  dis- 
proved by  the  saturated  dye,  the  extraordinary  resiliency,  the  functional 
energy,  for  example,  of  a  hypertrophied  biceps  brachii.  Least  of  all 
could  it  be  explained  on  the  ground  of  augmented  fat  formation — the 
effect  of  excessive  development  of  fat,  in  whatever  shape,  being  to  repel 
the  growth  of  muscle.  The  last  two  propositions  are  moreover  refuted 
by  the  hypertrophy  of  organic  muscles. 

The  examination  of  hypertrophied  hearts,  for  which  the  opportunity 
is  frequent,  offers  but  little  assistance  towards  the  solution  of  the  pro- 
blem, more  especially  where  the  increase  of  mass  is  considerable.  A  new 
accession  of  muscular  fibres  is  not  manifest.  On  the  contrary,  in  pro- 
portion to  the  diminished  energy  of  the  organ,  their  fibrils  are  found  in 
the  progress  of  reduction  to  a  partially  dark-colored  molecule,  and  of 
gradual  extinction.  One  thing  alone  is  evidently  adventitious,  namely, 


ANOMALIES    OF    SIZE.  45 

irregular  aggregations  of  an  amorphous  fibro-laminated  blastema,  co- 
piously interspersed  with  nuclei  in  different  grades  of  development  into 
areolar  tissue,  and  of  areolar  tissue  itself,  together  with  a  large  propor- 
tion of  free  fat  and  of  adipose  tissue. 

In  the  hypertrophy  of  organic  muscle  the  characters  are  more  clearly 
defined.  Here,  along  with  nuclei,  we  meet  with  little,  flat,  elongated, 
and  nucleated  bodies,  the  rudiments  of  new  fibres.  A  marked  instance 
of  hypertrophy  of  this  nature  is  afforded,  amongst  others,  by  the  preg- 
nant uterus,  which,  at  the  same  time,  exemplifies  the  disintegration  of 
fibre,  and  the  lingering  of  a  multiplicity  of  nuclei,  which  are  themselves 
eventually  absorbed. 

Even  hypertrophy  of  the  nervous  system  is  little  more  than  a  problem. 
The  development  of  fresh  nervous  filaments  is  unproved  and  even  impro- 
bable. Nor  is  the  enlargement  of  the  nerve-tubules  through  increase  of 
their  contents  more  readily  demonstrable.  In  the  central  organs,  and 
particularly  in  the  brain,  the  anomaly  consists  in  an  accumulation  of  the 
minute  granular  connecting  mass  interstitial  to  the  nerve-tubules.  At 
the  circumference  it  can  consist  only  of  an  augmentation  of  the  neuri- 
lemma.  In  the  ganglia  the  accession  of  new  ganglion-cells,  though  not 
ascertained,  is  rendered  probable  by  the  regeneration  of  excised  ganglia. 

One  of  the  hypertrophies  most  frequently  discussed  is  that  of  glandu- 
lar bodies.  We  shall  pass  over,  for  the  present,  the  false  hypertrophies 
so  frequent,  particularly  in  the  liver,  the  spleen,  and  the  kidneys.  That 
of  other — for  example,  the  mammary,  the  salivary — glands  may  consist 
in  an  augmentation  either  of  some  constituent  of  secondary  importance 
— for  example,  areolar  or  adipose  tissue — or  of  the  parenchyma  itself; 
and  it  is  with  evidence  respecting  this  last  form  that  we  are  here  princi- 
pally concerned. 

Examined  with  the  naked  eye,  the  parenchyma  of  the  enlarged  pro- 
state gland,  as  that  best  adapted  for  this  experiment,  certainly  appears 
to  have  undergone  an  increase  of  mass.  This  might  be  brought  about 
either  by  the  creation  of  new  acini  (lobules),  or  by  the  enlargement  of 
existing  ones,  through  the  apposition  of  fresh  enchyma-cells ;  or,  lastly, 
by  the  co-operation  of  both.  The  appearances  in  hypertrophy  of  the 
prostate  gland  render  the  new  formation  of  lobules  and  of  lobes  highly 
probable.  Henle's  observations,  however,  of  the  existence  of  solitary 
enchyma-cells  in  the  vicinity  of  the  glandular  lobules  in  the  lachrymal 
gland  of  a  calf,  and  still  more,  what  is  very  readily  witnessed,  in  hyper- 
trophied  thyroid  glands,  render  probable  the  new  formation  of  such 
gland-cells,  and,  through  the  resorption  of  their  partition  walls,  their 
blending  with  the  lobules  so  as  positively  to  enlarge  these. 

A  peculiar  kind  of  hypertrophy,  concurrent  with  dilatation  of  the 
cavities  of  the  acini,  is  a  very  frequent  cause  of  the  enlargement  of 
glandular  formations.  This  dilatation  is  due  to  an  augmented  secretion 
taking  place  within  the  follicles,  determined  by  the  same  local  or  general 
causes  as  the  hypertrophy  itself;  and  this  latter  consists  in  an  increase 
of  mass  in  the  investing  fibres  of  the  follicles.  This  condition  is  imme- 
diately followed  by  the  expansion  or  degeneration  of  the  follicle  to  a 
dilated  cyst-like  cell,  with  a  stouter  lamina  of  enveloping  fibres.  At  the 
same  time  the  secretion  may  become  alienated  both  in  quantity  and  in 


46  ANOMALIES    OF    SIZE. 

quality,  until  a  cyst  is  completed  with  contents  altogether  alien  to  the 
native  secretion  of  the  gland.  This  is  witnessed  in  the  follicles  of  the 
thyroid  gland,  in  the  Malpighian  bodies  of  the  kidneys,  in  the  Graafian 
follicles,  and  in  the  acini  of  the  salivary  glands ;  in  the  mucous  follicles, 
particularly  those  of  the  cervix  uteri,  where,  even  in  the  physiological 
state,  they  frequently  dilate  into  capacious,  thick-coated  cysts,  rupture, 
and  discharge  their  contents. 

Evidence  of  hypertrophy  of  the  liver,  of  the  spleen,  of  the  lymphatic 
glands,  is  hardly  obtainable. 

The  idea  of  a  hypertrophy  of  the  liver  from  the  accessory  formation 
of  new  hepatic  cells  would  not  indeed  be  discordant  with  our  notions  of 
the  functional  importance  of  that  organ.  All  anatomical  proof  is,  how- 
ever, unattainable.  That,  on  the  other  hand,  upon  which  it  more 
obviously  depends,  is  turgescence  of  the  hepatic  cells  from  an  increased 
proportion  of  fat  and  of  bile,  together  with  hyperaemia  of  the  capillaries. 
This  condition  determines  the  more  or  less  marked  development  of  what 
is  called  the  secreting  substance  of  the  liver, — one-sided  hypertrophy  of 
the  liver,  as  it  is  termed,  or  nutmeg  liver. 

Hypertrophy  of  the  spleen  must  be  referred,  first,  indeed,  to  the  rein- 
forcement of  its  fibrous  framework,  but  mainly  to  augmentation  of  the 
pulpy  parenchyma  of  the  spleen,  that  is,  of  the  elements  out  of  which  it 
is  constructed.  » 

Nor  can  hypertrophy  of  the  lymphatic  glands  be  well  traced  to  the 
adventitious  development  of  new  lymphatic  vessels  between  their  paren- 
chyma, but  rather  to  increase  of  the  parenchyma  between  the  lymphatic 
vessels.  It  is  certain,  at  least,  that  in  atrophy,  the  lymphatic  vessels 
become  deficient  in  parenchyma. 

Hypertrophy  of  the  lungs  consists  not  in  the  addition  of  new  cells,  but 
in  an  augmentation  of  matter  in  the  parietes  of  the  existing  ones.  The 
ample,  energetic  (vicariating)  function,  moreover,  of  a  hypertrophied 
lung  seems  to  imply  a  multiplication  of  the  capillary  vessels  by  the 
creation  of  new  ones.  Thus,  again,  hypertrophy  of  the  corpora  caver- 
nosa  does  not  depend  upon  the  addition  of  new  cellular  spaces,  or  their 
increase  through  the  development  of  new  septa,  but  upon  increase  of 
substance,  thickening  of  the  walls  of  the  cellular  spaces,  with  simulta- 
neous dilatation  of  these  latter. 

(b.)  False  hypertrophy. 

This  has  been  already  adverted  to  as  a  heterologous  product.  As 
such  it  occurs  frequently  in  the  form  of  infiltration.  False  hypertrophy 
is  for  the  most  part  cognizable  at  a  glance  from  the  alienation  which  the 
general  characters  of  the  organ  have  undergone.  Very  marked  hyper- 
trophies of  this  kind  are  found  to  affect  the  liver,  and  with  rather  less 
frequency  the  spleen  and  even  the  kidneys  ;  presenting,  in  the  instance 
of  the  two  former,  what  is  commonly  termed  hypertrophy,  physconia, 
engorgement,  &c.  These  manifest  themselves  in  the  shape  of  fatty  liver, 
waxy  liver,  of  albuminous,  lardaceous  infiltration  of  that  viscus,  of  the 
spleen,  of  the  kidneys,  and  they  will  be  reconsidered  under  the  head  of 
heterologous  growths.  They  not  rarely  attain  to  a  very  high  grade,  are 
always  distinguished  as  being  palpably  based  in  a  constitutional  dyscrasis, 


ANOMALIES    OF    SIZE.  47 

and  are,  proportionately  to  the  rapidity  or  slowness  of  their  develop- 
ment, attended  or  unattended  with  pain. 

To  these  hypertrophies,  moreover,  properly  belongs  the  ultimate 
degeneration  of  hypertrophied  and  dilated  glandular  follicles  into  cysts. 

Finally,  we  may  here  class  all  hypertrophies  founded  upon  products 
of  inflammation,  so  far  as  they  consist  in  the  adventitious  development 
of  a  blastema  foreign  to  the  texture  involved,  and  convertible  into  areolar 
and  fibroid  tissue. 

Hypertrophy  attacks  one,  or  a  few  disconnected,  but  for  the  most  part 
nearly  kindred  organs ;  or,  again,  an  entire  system — for  example,  the 
osseous,  the  lymphatic  system.  The  general  hypertrophy  called  poly- 
sarcia  or  corpulence,  consists  both  in  the  excessive  development  of  fat, 
and  in  extraordinary  succulence  of  the  soft  tissues,  more  especially  of 
the  areolar. 

Hypertrophied  organs  offer  a  variety  of  remarkable  changes.  The 
volume  is  usually  augmented, — more  obviously  so  in  the  case  of  false 
hypertrophies.  Now  and  then  the  natural  volume  is  retained,  the  failure 
of  increase  of  volume  being  compensated  for  by  augmented  density  of 
the  organ,  or  some  one  anatomical  constituent  becoming  hypertrophied 
at  the  expense  of  another  one,  which  wastes  in  a  corresponding  degree. 
In  hollow  organs  we  distinguish  between  a  simple  hypertrophy  with 
normal  capacity,  an  excentrical  with  dilatation,  and  a  concentrical  with 
diminution  of  the  cavity.  In  this  last  the  volume  of  the  organ  may  be 
augmented,  or  normal,  or  even  diminished.  Examples  are  afforded  in 
hypertrophies  of  the  heart,  of  the  uterus,  &c. 

The  weight  of  hypertrophied  organs  corresponds  with  their  increase 
of  volume  and  of  density. 

The  shape  always  undergoes  a  change  proportionate  to  the  degree  of 
the  enlargement.  Generally  speaking,  hypertrophied  organs  assume  a 
certain  roundness,  losing  their  edges,  their  angles,  and  their  flat  sur- 
faces. In  the  case  of  some  organs,  and  of  the  liver  in  particular,  the 
marked  character  of  such  disfigurement  is  not  devoid  of  pathognomonic 
significance. 

The  color  is,  in  true  hypertrophy,  the  normal — only  of  deeper  tint. 
Take,  for  example,  the  saturated  red  in  true  hypertrophy  of  muscular 
flesh,  the  saturated  twofold  coloration  of  nutmeg  liver.  In  false  hyper- 
trophy, the  coloration  suffers  various  alterations. 

The  consistence  of  a  hypertrophied  organ  is  often  unchanged,  often 
increased,  sometimes  diminished.  A  remarkable  degree  of  density  and 
of  resiliency  characterizes  hypertrophied  muscle,  more  especially  in  the 
right  ventricle  of  the  heart ;  and,  again,  in  hypertrophy  of  the  spleen 
referrible  to  mechanical  hyperaemia,  and  unattended  by  obvious  enlarge- 
ment. The  same  observation  applies  to  false  hypertrophies,  in  parti- 
cular to  brawn-like  infiltration  of  the  liver,  the  spleen,  and  the  kidneys. 
Fatty  degeneration  of  the  liver  is  marked  by  a  diminution  of  consistence. 

The  bloodvessels  of  hypertrophied  organs  sometimes  present  a  dilated 
calibre  and  thickened  (hypertrophied)  coats.  This  is  especially  percep- 
tible in  congestion  and  hypertrophy  of  long  standing ;  not  so,  or  at  least 
not  in  a  marked  degree,  in  other  cases.  Does  the  accessory  formation 


48  ANOMALIES    OF    SIZE. 

of  new  structural  elements  in  the  hypertrophied  organ  imply  that  of  new 
bloodvessels  likewise  ?  Direct  experience  affords  no  information  upon 
this  point.  In  relation  to  the  hypertrophy  of  vicariating  organs,  and  of 
the  lungs  more  particularly,  it  would  be  reasonable,  where  vicarious 
action  really  is  in  force,  to  take  for  granted  the  accessory  formation  of 
new  capillaries.  The  nerves  of  hypertrophied  organs  are  occasionally 
found  considerably  thicker  than  natural. 
The  causes  of  hypertrophy  are  : 

1.  Morbid  increase  of  the  quantity  of  blood  in  the  capillaries  of,  and 
retarded  circulation  in,  the  affected  organ  ;  repeated  and  abiding  hyper- 
aemia.     Examples  are  furnished  in  particular  by  the  frequent  hypertro- 
phies of  the  abdominal  viscera  arising  out  of  mechanical  hypersemia,  of 
the  mucous  membranes  in  organic  diseases  of  the  heart,  of  the  areolar 
tissue  in  the  lower  extremities  in  a  varicose  condition  of  their  veins,  and, 
lastly,  by  the  hypertrophies  of  the  mucous  membranes  brought  about  by 
the  hypersemia  entailed  by  repeated  inflammation. 

2.  Augmented,  violent  action  induced  by  various  direct  or  reflected 
stimuli.     Examples  present  themselves  in  hypertrophy  of  the  voluntary 
muscles,  of  the  heart,  of  the  organic  fleshy  tunics. 

3.  The  groundwork  of  a  lengthy  series  of  hypertrophies  consists  in  a 
constitutional  vice  of  nutrition  and  in  an  anomalous  blood-crasis.     The 
hypertrophy  is  here  the  expression,  th$  symptom,  of  general  impairment. 
This  applies  to  true,  and  with  greater  force  to  false  hypertrophy.     To 
this  class  belong  hyperostosis,  excessive  development  of  fat,  endemic 
goitre, — hypertrophy  of  the  brain,  and  hypertrophy  of  the  lymphatic 
glands  in  rhachitism, — the  excessive  development  of  fat  with  simulta- 
neous impairment  of  its  quality  in  alcohol-dyscrasis, — the  conditions  of 
fatty,  of  waxy  liver,  of  brawny  infiltration  of  this  organ,  of  the  spleen, 
of  the  kidneys  in  tuberculosis,  rhachitisms,  inveterate  syphilis,  &c. 

4.  Inflammation ;  the  result  of  which  is  so-called  inflammatory  hy- 
pertrophy, to  which  we  shall  have  to  recur  by-and-by.     It  engenders 
true  hypertrophy  in  areolar  and  osseous  textures  alone  ;  in  all  the  rest, 
through  the  fresh  deposition  of  areolar  and  of  fibroid  tissues,  false  hyper- 
trophy. 

Hypertrophies  of  both  kinds  are  either  congenital,  or,  what  is  far  more 
frequent,  acquired  during  extra-uterine  life. 

The  course  of  hypertrophies  is  for  the  most  part  chronic.  Neverthe- 
less, they  not  rarely  form  within  a  surprisingly  short  period,  or  from 
time  to  time  rapidly  increase.  They  are  then  often  painful  affections, 
as,  for  example,  the  acutely  developed  fatty  liver. 

Hypertrophy,  when  it  has  attained  a  high  degree,  impairs  the  function 
of  the  affected  organ,  whilst  the  latter,  by  its  increase  of  weight  and  of 
volume,  obstructs  the  function  of  neighboring  parts. 

Of  itself  it  commonly  proves  fatal  through  palsy,  the  result  of  the 
ultimate  disproportion  between  the  bulk  of  the  hypertrophied  organ  and 
the  powers  of  innervation.  As  examples  may  be  cited  hypertrophies  of 
the  heart,  palsy  of  the  hypertrophied  intestine  above  a  stricture,  palsy 
of  the  hypertrophied  urinary  bladder,  and  the  like. 

A  proper  discrimination  is  requisite  between  increase  of  volume  from 
hypertrophy  and  the  dilatation  of  hollow  organs,  more  especially  if  asso- 


ANOMALIES    OF    SIZE.  49 

elated  with  attenuation  of  the  parietes.  Dilatation  is  generally  coupled 
with  hypertrophy  of  the  walls  of  the  dilated  organ, — termed  active  dila- 
tation^ co-significant  with  excentrical  hypertrophy.  Simple  dilatation, 
in  which  the  walls  are  of  their  natural  thickness,  is  a  kindred  form.  Di- 
latation may,  however,  be  conjoined  with  attenuation  of  the  walls;  it  is 
then  denominated  passive  dilatation. 
*  The  causes  of  the  dilatation  of  hollow  organs  are  various. 

1.  Mechanical  impediments,  which  obstruct  the  free   passage   and 
egression  of  the  contents  of  the  different  canals  and  reservoirs.     They 
occasion  dilatation  either  beyond  or  behind  their   seat,  and  manifest 
themselves — 

(a.)  As  local  constriction  of  calibre,  through  pressure  from  without. 

(6.)  As  coarctation  consequent  upon  hypertrophy  and  change  of  tex- 
ture in  the  walls  of  the  organ.  In  instances  rare,  except  in  disease  of 
the  heart,  as  dilatation.  Thus,  whereas  in  the  intestinal  canal  it  is  the 
accumulation  of  its  contents,  on  the  other  hand,  in  dilatation  of  the 
orifices  of  the  heart  it  is  the  increased  diameter  of  the  blood-column,  in 
insufficiency  of  the  heart-valves  the  regurgitation  of  the  blood,  that 
furnishes  the  mechanical  impediment. 

(c.)  As  obturation  of  canals  with  substances  of  various  kinds,  whether 
introduced  from  without  or  begotten  within  the  organism,  whether  closing 
up  by  their  bulk  or  obstructing  by  their  aggregation, — in  a  word,  as 
foreign  bodies,  secretions,  &c. 

Other  local  causes,  however,  besides  the  above-mentioned — accumula- 
tions of  foreign  bodies,  of  self-engendered  deposits — are  in  like  manner 
productive  of  dilatation. 

2.  Paralysis  of  the  contractile  elements  in  the  walls  of  the  organ, 
whether  peripherous,  and  consecutive  to  mechanical,  concussive  violence, 
tension,  &c.,  to  disease  of  texture,   especially  inflammation;  or  deter- 
mined by  affection  of  the  nervous  centres. 

3.  Diseases  of  texture ;  for  example,  fatty  degeneration,  particularly 
of  the  heart. 

4.  Inflammations. 

The  different  causes  frequently  act  in  unison  in  various  sequences. 
Thus,  coarctation  begets  accumulation  of  contents.  This,  together  with 
a  certain  relative  amount  of  existing  dilatation,  occasions  paralysis  of 
the  organ.  The  paralysis  causes  dilatation,  and  thereby  accumulation 
of  the  contents,  which  again,  in  turn,  mechanically  promotes  the  dilata- 
tion. 

Dilatation  destroys  life  through  paralysis,  either  simply  or  with  the 
concurrence  of  asthenic  stasis,  inflammation,  and  gangrene,  towards  the 
establishment  of  which  the  contact  of  retained  contents  in  the  progress 
of  decomposition  contributes  its  part.  Take  for  example  the  intestinal 
canal,  the  urinary  bladder,  &c. 

Sudden  dilatation  is  wont  to  assume  the  passive  character,  a  superve- 
nient hypertrophy  being  more  marked  in  the  inverse  ratio  of  the  celerity 
with  which  the  dilatation  is  brought  about. 

Increase  of  volume  in  one  direction  at  the  expense  of  the  general  bulk 
of  the  organ,  the  result  of  forcible  tension,  is  distinct  from  hyper- 
trophy. 

VOL.  I.  4 


50  ANOMALIES     OF     SIZE. 


ABNORMAL   DIMINTJTIVENESS. 

Congenital  abnormal  diminutiveness  affects  the  entire  body,  as  dwarf 
stature  (microsomia),  the  individuals  being  termed  dwarfs,  or  pigmies. 
These  are  either  born  diminutive,  or,  owing  to  inherent  predisposition, 
not  developed  after  birth  to  the  ordinary  stature.  Dwarf-growth  mani- 
fests itself  either  in  the  corporal  development  remaining  stationary  at 
the  stage  of  childhood,  the  not  unpleasing  outlines  and  proportions  of 
which  it  then  retains,  or  else  it  is  founded  in  an  arrest  in  the  growth  of 
the  bones,  especially  those  of  the  lower  extremities,  with  simultaneous 
malformation  of  the  osseous  trunk.  It  is  marked  by  a  disproportion  in 
the  more  important  parts  of  the  body — largeness  and  hydrocephalic 
shape  of  the  skull ;  length  of  trunk  coupled  with  shortness  of  extremi- 
ties, especially  of  the  inferior  ones  ;  deformity  of  bones,  consisting  in 
thickness,  especially  of  the  articular  terminations.  This  latter  dwarf- 
formation  is  always  congenital,  and  the  bone  affection  upon  which  it  de- 
pends has  been  designated  as  congenital  rhachitis ;  against  which,  how- 
ever, we  have  as  yet  to  urge  that,  however  much  its  features  resemble 
those  of  the  rickets  of  childhood,  the  direct  evidence  of  its  identity  with 
the  latter  is  wanting. 

Accordingly,  dwarf-growths  may  depend,  either  upon  a  primitive  vice 
of  plasticity,  or  in  an  anomaly  of  development  affecting  specifically  the 
osseous  system.  Growth  may,  moreover,  become  checked  at  an  earlier 
or  later  period,  subsequent  to  birth,  by  constitutional  maladies  of  an  ex- 
hausting kind,  both  congenital  and  acquired,  and  especially  by  such  as 
affect  the  brain  or  spinal  medulla. 

Partial  diminutiveness  affects  individual  organs,  systems,  or  sections 
of  the  body.  It  is  founded  sometimes  in  a  primitive  anomaly  of,  or  in 
defective  plasticity  in,  the  germ ;  in  pressure  and  in  restriction  of  space 
within  the  uterus ;  or,  again,  in  a  hindrance  to  growth  after  birth,  re- 
sulting from  exhausting  diseases,  from  paralysis ;  lastly,  in  atrophy. 
Where  larger  sections  of  the  body  are  affected,  such  disproportions  result 
as  are  observed  in  giant-growth,  in  dwarf-growth,  and  in  numerous  de- 
scriptions of  monstrosity.  Although  it  may  affect  every  organ  and 
system,  it  is  nevertheless  most  conspicuous  in  the  following :  namely, 
the  brain  (and  skull)  [microcephalia] ;  the  eyes  [microphthalmus],  the 
inferior  maxilla  [brachygnathus],  the  lungs  (and  thorax),  the  stomach 
and  intestinal  canal,  the  common  integuments  (shortness),  the  muscles, 
the  skeleton,  the  heart  and  vascular  system  (especially  the  aortal),  the 
generative  apparatus. 

It  is  necessary  to  observe,  that — 

(a.)  In  monstrosities,  accessory,  supernumerary  parts  are  very  fre- 
quently diminutive. 

(b.)  Formations  checked  in  the  development  of  their  mass  and  volume, 
often  exhibit  an  arrest  in  the  development  of  their  texture  ;  for  example, 
bones,  muscles. 

(c.)  Preternaturally  diminutive  organs  often  display  some  other  kind 
of  deformity,  referable  to  the  same  causal  relations. 

(d.)  Next  to  diminutiveness  is  total  absence,  which,  in  reality,  often 


ANOMALIES     OF    SIZE.  51 

applies  to  individual  formations  entering  into  the  composition  of  a  com- 
plex part  or  system. 

In  hollow  organs  preternatural  diminutiveness  manifests  itself  as 
coarctation,  and  even  as  complete  imperviousness,  which,  when  affecting 
the  external  orifice  of  canals,  is  termed  imperforatio,  atresia. 

As  contrasting  with  hypertrophy,  atrophy  here  demands  a  special 
consideration. 

ATROPHY. 

Atrophy,  wasting  [tabes],  consists  in  the  withdrawal  from  a  forma- 
tion, after  it  has  reached  a  certain  grade  of  maturity  and  bulk,  of  its 
constituent  elements,  without  any  compensating  regeneration  of  these ; 
the  result  being  decrease  of  substance,  usually  coupled  with  diminution 
of  volume. 

G-eneral  atrophy  attacks  simultaneously,  or  in  rapid  succession,  many 
organs  and  systems,  if  not  all.  Partial  atrophy ',  one  organ  exclusively, 
or  at  least  preferably.  To  the  latter  we  shall  at  once  direct  our  atten- 
tion. 

As  with  hypertrophy,  so  every  organ  is  liable  to  become  affected  with 
atrophy. 

Atrophy  may,  in  the  first  place,  be  essentially  primary,  that  is,  de- 
veloped in  an  organ  as  its  first  and  sole  anomaly,  through  influences 
more  or  less  palpable,  but  external  to  such  organ.  Or,  again,  it  may  be 
secondary,  that  is,  the  result  of  previous  textural  alteration  in  the  organ. 
The  first  is  akin  and  analogous  to  the  periodical  intra-  and  extra-uterine 
processes  of  involution  of  certain  formations,  as  also  to  the  senile  atrophy 
or  marasmus  of  organs. 

Primary  partial  atrophy  is  often,  indeed,  purely  local ;  in  not  a  few 
instances,  however,  it  is  probably  conditional  upon-  a  general  derange- 
ment of  nutrition,  of  which,  in  such  case,  it  is  but  the  manifestation  or 
symptom. 

Causes  of  partial  atrophy  are  : 

1.  Diminished  supply  of  blood — of  alimentary  fluid — owing  to  com- 
pression, obturation,  coarctation,  or  obliteration  of  the  afferent  blood- 
vessels ;  for  example,  partial  atrophy  with  lobulation  of  the  liver  from 
adhesive  phlebitis  of  branches  of  the  portal  vein,  atrophy  of  the  cartila- 
ginous investments  of  the  joints  from  sclerosis  of  the  spongy  condyles, 
and  the  like.     Thickening  of  the  minute  and  capillary  vessels  from 
within  may  co-operate  with  ossification  of  the  great  arteries  in  producing 
atrophy,  especially  in  the  brain,  by  rendering  the  walls  of  such  vessels 
impermeable  to  the  plasma  of  the  blood. 

2.  Exhausting  disease,  or  healing  process ;  for  example,  atrophy  of 
the  bones  and  of  their  adjacent  soft  parts  as  a  consequence  of  caries,  of 
destructive  suppuration  in  the  effort  to  repair  injuries ;  atrophy  of  the 
uterus  after  childbed,  and  exhausting  puerperal  diseases,  &c. 

3.  Diminished  innervation,  paralysis,  or  impeded  action  of  an  organ 
owing  to  mischief  of  a  mechanical  nature;  for  example,  atrophy  of 
muscles  in  anchylosis,  in  luxations. 

4.  Pressure  and  distension. — These  occasion  increased  absorption,  a 
species  of  atrophy  designated  by  the  term  detritus,  usura.     Even  the 


52  ANOMALIES     OF    SIZE. 

most  stubborn  textures  are  not  proof  against  it,  the  rigid  osseous  texture 
itself  being  in  a  high  degree  susceptible  of  it.  It  not  unfrequently  ad- 
vances to  the  degree  of  a  lesion  of  continuity. 

5.  Anomalies  affecting  general  nutrition,  and   the  blood-crasis  in 
particular. — Upon  such  are  based,  for  example,  perhaps,  the  untimely 
decline  (involution)  of  the  generative  organs  in  either,  but  especially  in 
the  male  sex ;    but  with  more  of  certainty,   several  painful  kinds  of 
atrophy  of  the  osseous  system.     Acute  yellow  atrophy  of  the  liver  is 
unquestionably  founded  upon  an  anomaly  of  the  crasis,  whilst  the  thyroid 
gland  is  atrophied  by  the  fluids  becoming  impregnated  with  iodine. 

6.  Consecutive  atrophy  depends,  as  already  stated,  upon  a  previous 
alteration  of  texture,  a  breaking  up  thereof  through  hemorrhage  (apo- 
plexy), inflammation,   and   heterologous  growths.      Two   contingencies 
may  here  arise ;  either  the  adventitious  product  and  also  the  disabled 
textural  elements  of  the  organ  may  both  undergo  absorption,  or   else 
these  latter  may  waste  away  alone,  leaving  in  their  place  the  new  pro- 
duct, in  the  original  or  in  subsequently  diminished  proportion  and  inde- 
finite shape.     Exemplifications  occur  in  cell-infiltration  of  the  medullary 
substance  of  the  brain  consequent  upon  encephalitis ;  in  atrophy  of  the 
kidneys,  resulting  from  inflammation  or  from  Bright's  granular  disease ; 
finally,  in  the  merging  of  muscular  fibre  in  the  fatty  degeneration  of 
muscle  and  of  normal  textures  in  heterologous  growths. 

The  morphological  process  connected  with  atrophy  is  not  known  in 
detail.  To  judge  by  a  few  facts — for  example,  the  reduction  of  the 
uterus  after  delivery,  the  perishing  of  muscular  fibre  in  fatty  degenera- 
tion, the  wasting  of  nerves,  of  lymphatic  glands — the  process  essentially 
consists  in  the  breaking  down  and  liquefaction  of  the  secondary  elements 
(fibre),  resulting  from  the  metamorphosis  of  the  cells  and  from  the  cells 
themselves.  The  nuclei  at  first  remain,  but  subsequently  undergo  the 
same  reduction  and  ultimate  resorption.  In  the  case  of  new  growths, 
this  blastema,  arising  out  of  the  wreck  of  the  said  elementary  bodies, 
may  become  subservient  to  the  construction  of  anomalous  textures. 

With  respect  to  the  changes  suffered  by  atrophied  organs  in  their 
physical  properties,  we  may  offer  the  following  general  remarks. 

The  volume  of  the  atrophied  organ  is  indeed  very  commonly  dimi- 
nished, membranous  formations  having  become  thinner  :  this  is,  however, 
by  no  means  invariably  or  immediately  the  case,  at  least  not  in  any 
marked  degree  ;  for  example,  in  atrophy  of  the  lungs  or  of  the  bones. 
In  hollow  organs  the  volume  may,  owing  to  a  coexistent  passive  dilata- 
tion, even  become  augmented.  In  such  organs  atrophy  is  conjoined 
either  with  normal  capacity,  simple  atrophy ;  or  else  with  dilatation  of 
the  cavity,  so-called  eccentrical  atrophy — for  example,  of  the  heart,  of 
the  uterus,  &c. ;  or,  lastly,  with  coarctation,  concentrical  atrophy,  in 
which  the  depth  of  the  walls  may  be  natural,  or  even  greater  than 
natural. 

The  weight  of  atrophied  organs  may  be  reduced,  normal,  or  even  in- 
creased :  in  the  first  case,  proportionately  to  the  simplicity  of  the  atrophy ; 
in  the  two  latter  cases  the  atrophy  is  consecutive,  new  growths  supplant- 
ing the  original  textures. 

The  shape  of  atrophied  organs  embraces  a   variety  of  anomalies; 


ANOMALIES     OF     SIZE.  53 

amongst  which  we  may  specify  the  deformity  which  attaches  to  the  con- 
centrical  wasting  of  hollow  organs  and  organs  of  cellular  structure  like 
the  bones,  the  removal  of  the  incisura  interlobularis  in  atrophy  of  the 
lungs,  the  tuberous  gland-like  surface  in  secondary  atrophy  of  the 
kidneys,  &c. 

The  structure  of  atrophied  organs  involves  various,  and  occasionally 
very  marked  changes.  Thus,  organs  of  cellular,  of  cavernous  structure, 
by  dint  of  the  absorption  which  takes  place  at  the  parietes  of  their  cells 
and  canals,  are  rendered  wide-celled — for  example,  in  the  lungs  and  in 
bones  ;  and  this  structure  eventually  dwindles  into  a  mere  net  or  trellis- 
work.  In  consecutive  atrophy,  a  new  growth  of  a  completely  different 
texture  occupies  the  place  of  the  original  structure ;  after  inflammation, 
for  instance,  a  honeycombed,  meshy,  or,  on  the  contrary,  a  dense, 
callous,  areolar  tissue. 

The  consistence  is  in  like  manner  subject  to  many  changes.  It  is 
sometimes  diminished,  readily  giving  rise,  upon  slight  occasion,  to  lesions 
of  continuity ;  in  the  osseous  system,  for  example.  Sometimes  it  is  in- 
creased. Secondary  atrophy  presents,  in  a  marked  degree,  either  con- 
tingency, according  to  the  particular  change  of  structure.  Acute 
processes  of  the  reduction  of  mass  and  volume  determine,  in  certain 
organs,  rather  a  decrease — chronic  reduction  rather  an  increase — of 
consistence. 

Atrophied  organs  have  a  tendency  to  paleness  of  color.  This,  how- 
ever, in  some  measure  accords  with  certain  changes  affecting  the  native 
pigment  of  organs ;  for  example,  the  decoloration  of  muscle,  of  the  spleen 
to  rust-brown,  fawn-color,  or  yeast-color.  The  rule  itself  is,  moreover, 
subject  to  sundry  exceptions.  Thus,  the  pure  white  of  the  medullary 
substance  of  the  brain  is  exchanged  for  a  whitish-brown.  Organs  that 
become  atrophied  without  a  proportionate  thinning  of  their  capillaries, 
sometimes,  by  dint  of  a  relatively  augmented  supply  of  blood,  assume  a 
deeper  color ;  for  example,  bones,  kidneys.  At  the  same  time  much  de- 
pends upon  the  character  of  the  atrophy ;  as  in  the  cases  of  red  and 
yellow  atrophy  of  the  liver. 

The  bloodvessels  of  atrophied  organs  become  reduced  in  calibre,  col- 
lapsed, and  finally  cut  off  from  the  atrophied  organ,  that  is,  the  connec- 
tion interrupted  between  its  obliterated  capillaries  and  the  vascular 
trunk.  This,  however,  has,  in  like  manner,  its  exceptions,  as  in  the  case 
of  dilatation  of  the  trunk  and  ramifications  of  the  pulmonary  artery  in 
atrophy  and  in  emphysema  of  the  lungs  ;  in  the  case  of  dilatation  of  the 
bloodvessels  of  the  brain,  in  atrophy  of  this  organ. 

The  nerves  of  atrophied  organs  in  all  probability  dwindle  pari  passu 
with  the  wasting  of  the  diseased  textures. 

Atrophy  is  sometimes  an  acute,  but  more  commonly  a  chronic  process. 
In  the  former  case  it  is  frequently  a  painful  affection. 

The  consequences  of  partial  atrophy  differ  vastly  in  different  organs. 
Either  they  are  limited  to  a  small  range,  to  the  locality  itself,  or  they 
implicate  more  or  less  sensibly  the  entire  organism.  In  this  respect, 
atrophy  of  the  central  organs  of  the  nervous  system,  and  of  the  organs 
presiding  over  the  preparation  of  the  blood  and  over  the  grand  secretory 


54  ANOMALIES    OF    FORM. 

functions,  namely,  of  the  lungs,  liver,  and  kidneys,  is  of  course  foremost 
in  importance. 

G-eneral  atrophy  in  the  form  of  emaciation,  consumption,  affects, 
indeed,  the  entire  body,  but  by  no  means  all  organs  and  systems  simulta- 
neously or  in  an  equal  degree.  Next  in  order  to  the  falling  off  in  the 
amount  of  blood,  is  that  of  the  adipose,  the  areolar,  and  kindred  tissues  ; 
then  follows  that  of  the  voluntary  muscles,  then  of  the  organic  fleshy 
tunics  and  of  parenchymatous  organs,  lastly  of  bones ;  whilst,  even  in 
the  highest  grades  of  the  affection,  the  nervous  system,  so  far  as  relates 
to  its  constituent  elements,  remains  exempt.  This  order  is,  however, 
subject  to  many  exceptions.  The  wasting  of  several  formations  low  in 
the  scale  above  laid  down,  occurs  primitively,  and  offers  the  starting- 
point  for  the  atrophy  of  the  rest ;  for  example,  atrophy  of  bone. 

The  causes  are  loss  of  fluids  of  whatever  kind,  deficient  reproduction 
of  organic  substance,  fasting,  various  affections  of  the  digestive  organs, 
bodily  and  mental  exertion,  inordinate  activity  of  the  nervous  system  in 
various  ways,  excessive  heterologous  development,  dyscrasis  of  the  blood. 

It  is  not  rarely  combined  with  the  hypertrophy — for  the  most  part, 
false  hypertrophy — of  internal  organs,  especially  of  the  liver,  spleen, 
and  lymphatic  glands. 

A  peculiar  form  of  partial  diminution  is  represented  in  the  coarctation 
of  canals  and  cavities.  It  is  often,  indeed,  essentially  a  concentrical 
atrophy.  It  may,  however,  arise  from  external  pressure,  from  deficiency 
of  contents,  from  continued  irritation  of  the  sensitive  parietes,  or  even 
from  hypertrophy  of, — or  from  various  heterologous  luxuriations  and 
changes  of  texture  implicating, — the  said  parietes.  The  highest  grade 
manifests  itself  as  morbid  closure  (atresia). 


CHAPTER  III. 

ANOMALIES  OF  FORM. 

Anomaly  of  form,  or  deformity,  affects  either  the  entire  body  or  por- 
tions of  it  only, — general  or  partial  deformity.  It  is  either  primitive  or 
acquired;  simple  or  complicated,  that  is,  conjoined  with  anomalies  of  a 
different  nature. 

G-eneral  deformity  is  rare,  even  as  relates  to  very  faulty  abortions. 

To  primitive,  simple  partial  deformities  belong— 

(a.)  Those  in  which  any  part  is  preternaturally  long,  broad,  thick, 
spherical,  angular,  curved,  &c. ;  for  example,  oval,  vertical  pupil, 
oblique  uterus. 

(5.)  The  division  of  parenchymatous  organs  into  two  or  more  parts, 
by  extraordinary  lobulation  (the  lungs,  liver,  spleen,  kidneys);  the 
section  of  hollow  organs  by  the  inordinately  sharp  partition  of  a  naturally 


ANOMALIES     OF    FORM.  55 

double  cavity,  or  by  septformation  in  a  cavity  normally  single ;  for 
example,  double  apex  of  the  heart,  bilocular  uterus. 

Many  of  the  former,  and  still  more  of  the  latter  kinds  bear  the  impress 
of  arrest  of  development,  and  present  the  images  of  brutes. 

Amongst  primitive  complicated  deformities  may  be  classed  most  of 
the  instances  of  disproportion  and  of  absence  of  symmetry  manifested  in 
the  preternatural  volume  of  individual  organs  or  sections  of  organs; 
secondly,  those  consisting  in  abnormal  position,  abnormal  association, 
coalition  or  cleftformation ;  and,  lastly,  those  founded  in  the  superfluity 
or  in  the  deficiency  of  parts. 

Pre-eminent  amongst  them  are  hermaphrodites.  The  forms  of  herma- 
phroditism,  strictly  considered,  range  under  several  of  the  heads  just 
specified  as  conditional  upon  anomalies  of  shape.  It  would,  however, 
appear  most  suitable  to  discuss  them  here  under  a  single  head,  seeing 
that  from  one  or  more  fundamental  anomalies  inductive  of  herinaphroditism 
there  often  results  a  marked  deformity  of  the  generative  organs ;  seeing 
also  that  the  character  of  many  of  them  consists  essentially  in  a  de- 
parture from  the  normal  type.  They  are,  in  the  great  majority  of  cases, 
arrests  of  development. 

In  strict  analogy  with  the  relations  of  lower  orders  of  animals,  those 
malformations  should  be  designated  as  hermaphrodites,  in  which  the 

fenerative  organs  of  both  sexes  are  found  united  in  a  single  individual, 
uch  monstrosities  have,  from  time  immemorial,  been  abundantly 
described.  We  must,  however,  unite  with  Joh.  Muller  and  Th.  Bischoff 
in  rejecting  the  great  majority  of  these  examples.  Bischoff  has  pointed 
out  the  numerous  sources  of  error  by  which,  in  such  cases,  a  judgment 
may  be  warped ;  as,  for  instance,  the  great  resemblance  between  the 
generative  organs  of  the  two  sexes  at  an  early  period,  the  uniform  type 
in  the  development  of  both,  the  coalition  of  the  corpora  Wolffiana,  the 
errors  formerly  prevalent  as  to  the  primitive  identity  of  both  sexes.  It 
is,  therefore,  easily  intelligible  that  a  judgment  to  be  relied  upon  can 
alone  be  based  upon  a  familiar  knowledge  of  the  progressive  development 
of  the  genital  organs,  and  of  their  elementary  structure.  The  coexistence 
of  testicles  and  of  ovaries  on  the  same  side  has  been  thrown  into  entire 
discredit  by  the  arguments  of  Joh.  Muller,  who  nevertheless  admits  the 
occurrence  of  ovaries  on  one  side  and  of  testicles  on  the  other.  Th. 
Bischoff,  however,  impugns  the  accuracy  even  of  the  latter  observation. 
Nor  will  Bischoff  unconditionally  admit  the  numerous  cases  of  other 
portions  of  the  genital  organs  alleged  to  have  been  found  bisexual  on 
the  same  side,  or  male  on  the  one  side  and  female  on  the  other.  The 
history  of  development,  he  affirms,  sufficiently  teaches  us  that  this  species 
of  simulation  may  be  the  result  partly  of  an  arrest,  partly  of  a  peculiar 
modification  in  the  type  of  development.  Moreover,  the  progressive 
development  of  the  uterus,  of  the  seminal  vesicles,  of  the  prostate  gland, 
and  of  Cowper's  glands,  in  both  sexes,  still  remains,  notwithstanding  the 
skilful  investigations  of  J.  Muller,  Rathke,  Valentin,  so  far  matter  of 
uncertainty  that  we  can  hardly  derive  any  support  from  analogy  with 
the  normal  state. 

Strictly  speaking,  therefore,  neither  in  man  nor  in  the  higher  animals, 
can  hermaphroditism,  that  is,  the  coexistence  of  testicles  with  ovaries, 


56  ANOMALIES    OF    FORM. 

occur.  So  far  as  relates  to  these  essential  organs  of  generation,  there 
can  be  but  male  or  but  female  individuals.  On  the  other  hand,  the  rest 
of  the  genital  organs,  which  in  their  rudimental  condition  closely 
resemble  each  other  in  the  two  sexes,  may,  owing  to  some  anomaly  in 
the  mode  of  their  development,  assume  in  a  male  individual  more  or  less 
of  the  feminine,  in  a  female  individual  more  or  less  of  the  masculine 
form — and  thus,  in  either  case,  the  semblance  of  both  combined. 

If,  with  Bischoff,  we  rightly  discard  from  hermaphroditism,  cases  of 
individuals  with  throughout  female  organs  but  masculine  habit,  and, 
again,  with  perfect  male  organs  and  feminine  habit — irrespectively  of  a 
simply  undersized  penis  or  a  preternaturally  developed  clitoris — we  may, 
consistently  with  our  usual  classification,  divide  hermaphrodites  into — 

1.  Those  which  being,  as  to  the  essential  organs  of  generation  (testi- 
cles and  ovaries),  distinctly  male  or  female,  exhibit  nevertheless  some 
anomaly  of  development  [be  it  arrest,  overgrowth  (up  to  the  masculine 
type),  or  disproportion  of  some  other  kind]  more  or  less  typical  of  the 
opposite  sex. 

(a.)  Hypospadia  in  its  highest  grades,  namely,  on  the  one  side  with 
cleft  scrotum  and  the  formation  of  a  vagina-like  sinus — on  the  other 
side,  as  its  analogue,  diminutive  vagina,  closure  thereof  into  a  raphe'  or 
suture,  partial  or  entire  absence  of  this  organ,  with  a  clitoris  developed 
into  the  semblance  of  a  penis  hypospad^us,  or  one  completely  channelled 
with  a  urethra. 

(b.)  CryptorcMsm :  concealed  testicles  in  the  one  case ;  in  the  other 
its  parallel  condition,  descent  of  the  ovaries  into  the  greater  labia 
pudendi.  Now  and  then  associated  with  the  foregoing  form. 

High  grades  of  these  anomalies  constitute  the  so-called  transverse  her- 
maphroditism, implying  external  organs  of  the  one  and  internal  of  the 
other  sex.  The  case  of  externally  female  and  internally  male  organs  is 
by  far  the  more  common,  because  due  to  an  arrest  in  the  development 
of  the  male  organs,  whilst  the  opposite  case  depends  upon  the  ulterior 
development  of  the  female  organs  into  the  male  type. 

(c.)  The  occurrence  in  the  male  sex  of  a  womb-like  organ. 

These  cases  collectively  constitute  what  is  termed  spurious  hermaphro- 
ditism. 

2.  Lateral   hermaphroditism.      The   presence   of  testicles   and   vas 
deferens,  with  or  without  seminal  vesicles,  on  one  side,  and  of  ovarium 
and  tube  on  the  other.     It  has  been  before  stated  that  Bischoff  attaches 
little  credit  to  these  alleged  cases  of  the  coexistence  of  testicle  with 
ovary. 

3.  True  hermaphroditism  (hermaphrodite  per  excessum,  androgynus, 
coexistence  of  male  and  of  female  organs  on  the  same  side).     With  refe- 
rence to  these  cases,  recorded  by  Meckel  and  by  Gurlt,  Bischoff  remarks 
that  not  a  single  one  offers  conclusive  evidence  of  the  union  of  the  two 
main  organs  of  generation,  the  testicle  and  ovary,  and  that  the  seeming 
dualism  of  the  rest  of  the  organs  is  explicable  according  to  principles  of 
normal  development. 

Amongst  acquired  deviations  of  form  are  to  be  enumerated,  first,  those 
conditional  upon  hypertrophy  and  atrophy ;  upon  change  of  locality  and 
of  connection — as,  for  instance,  hernia,  prolapse,  oblique  position  of  the 


ANOMALIES     OF    POSITION.  57 

uterus  from  one-sided  traction,  luxation ;  upon  mechanical  interference 
— for  example,  amputation,  extirpation  ;  upon  cicatrization  ;  and,  lastly, 
those  malformations  of  organs  which  essentially  depend  upon  alterations 
of  texture — misshappen  liver,  for  instance. 

The  most  frequent  and  marked  kinds  of  deformity  are  founded  upon 
anomalies  of  the  osseous  system ;  for  instance,  curvatures  of  the  spine,  of 
the  long  cylindrical  bones,  dislocations,  preternatural  articulations,  &c. 


CHAPTER    IV. 

ANOMALIES  OF  POSITION. 

PRETERNATURAL  position — situs  mutatus,  inversus,  alienus,  dislocatio, 
ectopia — is  either  congenital  or  acquired.  In  either  case,  it  may  affect 
a  single  organ  or  implicate  several. 

To  congenital  anomalies  of  the  kind  belong : 

1.  The  re-establishment  of  symmetry,  in  lateral  asymmetria.     For 
example,  each  lung  is  found  to  have  two  lobes  only,  with  both  liver  and 
heart  in  the  centre.     This  is  probably  an  arrest  of  development,  these 
organs  originally  occupying  the  median  line,  and  being  in  appearance 
symmetrically  constituted. 

2.  Lateral  transposition,  displacement  from  side  to  side,  affects  either 
only  individual  organs  of  the  thoracic  or  abdominal  cavities — the  caecum 
being,  for  instance,  on  the  left,  the  heart  on  the  right  side ;  or  else  it 
affects  the  aggregate  of  the  thoracic  or  of  the  abdominal  viscera ;  or, 
lastly,  and  most  commonly,  the  collective  organs  of  both  these  cavities 
at  once.     The  type  of  formation  is  reversed,  the  right  greater  lobe  of 
the  liver,  for  instance,  becoming  the  left,  the  left  becoming  the  right, 
the  gall-bladder  lying  to  the  left  of  the  longitudinal  fissure.    As  regards 
the  cause,  it  appears  to  Bischoff  that  in  the  embryo  at  an  early  period, 
the  umbilical  vesicle,  after  development  of  the  intestine,  verges  towards 
the  left,  and  the  allantois  towards  the  right,  whereby  a  peculiar  spiral 
revolution  of  the  embryo  is  effected,  which  may  possibly  influence  the 
position  of  the  internal  organs.     It  is  conceivable  that  a  change  in  the 
position  of  the  germinal  vesicle  in  the  ovum  might,  in  like  manner,  give 
rise  to  a  transposition  of  organs. 

3.  Transposition  from  above  and  below.     Thoracic   organs   in  the 
abdomen  ;  abdominal  in  the  thorax. 

4.  Transposition  from  front  to  back ;  for  instance,  in  the  case  of 
teeth,  in  distortion  of  the  extremities. 

5.  Displacement  of  individual  organs  from  the  median  line,  as  for, 
instance,  of  the  falx  (cerebri), — of  the  uterus.     Displacement  upwards, 
as  in  cervical  position  of  the  heart.     Displacement  downwards,  as  in 
abdominal  site  of  the  heart,  pelvic  position  of  the  kidneys. 

Anomalous  origin  and  distribution  of  arteries  and  veins.  The  more 
important  examples  hereof  will  be  discussed  under  the  head  of  special 
anomalies  of  the  heart.  They  originate,  for  the  most  part,  from  blood- 


58  ANOMALIES     OF     POSITION. 

vessels  which  should  have  become  further  developed  stopping  short  in 
their  progress,  whilst  others  which  should  have  remained  diminutive,  or 
even  have  disappeared,  persist  and  become  more  strongly  developed. 
The  majority  represent  types  proper  to  different  vertebrata — to  fishes, 
amphibia,  birds,  and  mammalia. 

The  preternatural  position  of  certain  organs  which,  in  their  develop- 
ment, undergo  locomotion  to  a  considerable  extent,  is  specially  termed 
deviation,  aberration.  An  example  offers  in  the  descent  of  the  testicle 
beneath  the  femoral  arch  or  into  the  peringeum.  In  truth,  many  anoma- 
lies of  position  are  founded  in  an  early  aberration  in  this  sense.  The 
same  designation  is  applied  to  anomalies  in  the  origin,  course,  and 
ramification  of  vessels. 

Acquired  transposition  is  of  various  kinds,  and  many  of  these  so 
closely  resemble  the  congenital  forms,  as  with  difficulty  to  be  distin- 
guished from  them.  Their  import  varies  greatly,  proportionally  to — 

(a.)  The  importance  of  the  organ  displaced ; 

(b.)  The  number  of  organs  displaced ; 

(e.)  The  extent  of  the  displacement ;  and 

(d.)  Especially  to  the  rapidity  with  which  the  dislodgment  takes  place, 
and  to  the  corresponding  strain  upon  various  formations,  more  particu- 
larly bloodvessels  and  nerves. 

(e.)  The  extent  of  the  morbid  complication  to  which  the  displacement 
is  due ;  for  example,  mechanical  injury  to  the  surrounding  parts. 

(/.)  The  degree  of  embarrassment  to  which  the  dislodged  organs  be- 
come subject ;  for  instance,  limitation  of  space,  incarceration,  exposure 
to  the  external  air,  &c. 

(</.)  The  amount  of  functional  embarrassment  inflicted  upon  organs  by 
the  displaced  parts ;  for  example,  upon  the  lungs  by  the  intrusion  of 
abdominal  viscera  into  the  thoracic  cavity. 

These  transpositions  are,  moreover,  spontaneous,  where  the  organ 
changes  its  position  owing  to  increase  of  volume,  of  mass,  or  of  weight, 
in  which  case  it  commonly  sinks  into  a  lower  region.  Or  else  they 
depend  upon  conditions  extraneous  to  the  organ  displaced ;  to  which  class 
belong  dislodgments  consequent  upon  atony  of  investing,  supporting, 
attaching  formations,  especially  when  of  a  muscular  and  fibrous  nature. 
Or  they  are  referable  to  tonic  spasm  and  retraction  of  fleshy,  of  tendi- 
nous, and  of  ligamentous  formations,  as  exemplified  in  hernia,  in  curva- 
ture and  distortion  of  the  spine,  in  luxations,  in  club-foot,  &c.  Lastly, 
we  have  to  mention  the  displacement  of  organs,  through  tumors,  through 
dislodged  or  enlarged  neighboring  organs,  through  accumulated  fluids, 
and  the  like. 

The  more  important  forms  of  displacement  are : 

1.  Hernia  ;  the  extrusion  of  one  or  more  viscera,  or  of  merely  a  por- 
tion of  a  viscus,  out  of  its  natural  cavity  into  a  sac  formed  by  the  cir- 
cumscribed dilatation  of  the  membranous  investments  of  that  cavity 
(hernial  sac). 

2.  Prolapsus;  the  naked  extrusion  of  a  viscus  through  a  natural 
orifice.     It  is  either  complete  or  only  partial ;  the  former  case  occurs 
in  hollow  organs — for  example,  in  the  rectum,  in  the  prolapsed  and 
inverted  womb.     At  an  external  opening  of  the  body  intussusception 


ANOMALIES    OF    CONNECTION.  59 

ecomes  prolapsus,  which  is  intussusception  minus  the  external  layer  or 
sheath. 

3.  Protrusion,  propendentia,  of  viscera,  owing  to  congenital  fissure, 
or  to  rupture  or  penetrating  wounds  of  the  parietes  of  cavities. 

Again,  the  position  of  organs  may  be  anomalous,  independently  of  any 
change  of  place,  simply  by  preternatural  inclination,  especially  in  the 
shape  of  obliquity.  This  species  of  deviation  is  sometimes  primitive  and 
congenital,  sometimes  acquired.  It  affects  the  eye,  the  heart,  the 
stomach,  the  uterus,  the  teeth,  &c.  It  is  frequently  coupled  with  obli- 
quity of  form,  as  in  the  case  of  the  uterus. 


CHAPTER  Y. 

ANOMALIES  OF  CONNECTION. 

THESE  anomalies  (vitia  nexus)  consist  in  diminution  or  total  absence, 
or  else  in  enhancement  of  the  natural  connection  and  contiguity  of  organs. 
They  are  both  primitive  and  acquired,  and,  in  either  case,  exceedingly 
various  in  degree  and  extent.  To  the  former  belong  the  opposite  ex- 
tremes of  cleft-formation,  and  of  malformation  from  fusion,  together  with 
atresia. 

1.  Cleft-formations. 

(a.)  A  considerable  number  of  these  have  their  foundation  in  the 
germ  being  originally  a  membranous  expansion,  the  edges  of  which 
incline  towards  each  other,  eventually  meet,  and  thus  form  into  cavities 
or  cylinders. 

The  two  cavities  developed  out  of  the  animal  layer  of  the  germ,  for 
the  inclosure  of  the  central  nervous  system  and  of  the  organs  of  the 
neck,  the  thorax,  and  the  abdomen,  are  formed  out  of  the  union  of  the 
so-termed  abdominal  and  visceral  plates.  Now,  supposing  the  union  of 
the  edges  of  these  plates  not  to  take  place  at  all,  or  to  take  place  but 
imperfectly ;  or  supposing  consummated  union  to  become  redissolved 
through  some  agency,  like  the  accumulation  of  watery  fluid ;  there  would 
result,  either  anteriorly  or  posteriorly,  and  commonly  at  the  median 
line,  although  often  elsewhere,  a  cleft  or  gap,  attended  by  prolapse,  or 
even  by  destruction  of  the  implicated  viscera. 
Clefts  of  this  kind  are  : — 

Cleft  skull  (hemicephalia). 

Cleft  spine  (spina  bifida). 

Cleft  countenance. 

Cleft  cheek.  • 

Cleft  palate. 

Cleft  upper-lip. 

Cleft  tongue. 

Cleft  in  the  thorax. 

Cleft  in  the  abdomen. 

Cleft  in  the  pelvis. 


60  ANOMALIES     OF    CONNECTION. 

Cleft  urinary  bladder,  so  termed  prolapsus,  inversio  vesicae. 
Cleft  dorsum  penis  (epispadiasis). 

The  last  two  are  generally  combined  with  cleft  pelvis. 

The  intestinal  canal  is  in  like  manner  developed  out  of  an  expansive 
formation,  the  united  vascular  and  vegetative  layers  of  the  germ,  by  the 
approximation  of  its  edges,  out  of  a  groove  in  front  of  the  vertebral 
column.  Hence,  clefts  occur  in  the  intestinal  canal,  in  the  stomach,  as 
arrested  growths. 

(b.)  Other  clefts,  besides  those  mentioned,  originate  in  the  gaps  which 
occur  during  the  normal  development  of  particular  parts,  not  closed  at 
the  proper  time.  To  these  belong : 

Cleft  choroid  membrane  and  iris  (coloboma  iridis).  In  the  embryos 
of  all  vertebrata  we  meet,  at  an  early  period,  at  the  inner,  lower  angle 
of  the  eye,  with  a  narrow  colorless  stripe  in  the  choroid  membrane, 
which  commonly  disappears  before  the  iris  becomes  developed.  When 
this  stripe  continues  beyond  this  period,  it  often  abides  in  the  iris,  and 
is  perceptible  after  birth. 

Cleft  at  the  side  of  the  neck,  congenital  fistula  of  the  neck,  founded 
in  the  mode  of  development  of  the  visceral  cavity  of  the  head.  The  vis- 
ceral edges  of  the  animal  layer  of  the  germ  do  not  grow  towards  each 
other  in  continuity,  but  in  ridges,  termed  visceral  or  branchial  arches, 
which  are  parted  by  fissures,  termed  visceral  or  branchial  clefts.  When 
the  early  closure  of  these  does  not  take  place,  occasion  is  given  to  the 
somewhat  rare  malformation  in  question. 

Cleft  urethra  and  scrotum  (hypospadiasis}  of  various  grades.  At  an 
early  period  is  discoverable,  at  the  lower  side  of  the  rudiment  of  the 
penis,  a  groove,  which  extends  to  the  common  orifice  of  the  urinary  and 
sexual  organs.  In  the  male,  the  edges  of  this  groove  being  brought  into 
apposition,  coalesce  into  a  raphe  or  suture,  and  thus  form  at  once  the 
scrotum  and  the  urethra.  Where  this  process  wholly  or  partially  fails, 
there  arises  a  malformation  which,  if  the  penis  be  at  the  same  time  short 
and  the  testicles  retained  within  the  abdomen,  simulates  female  develop- 
ment— a  form  of  spurious  hermaphroditism. 

To  this  malformation  succeeds — 

Cloacal  formation,  junction  of  the  orifice  of  the  anus  and  of  the  external 
orifice  of  the  urinary  and  sexual  organs — a  formation  which,  being  at  an 
early  period  normal,  may,  through  an  arrest  of  development,  become 
persistent.  In  the  male  it  is  necessarily  associated  with  the  last-men- 
tioned vice  of  formation,  that  is,  with  hypospadiasis,  frequently  also  with 
cryptorchism. 

(<?.)  As  cleft-formations  may  likewise  be  reckoned  the  persistence  of 
certain  communicating  apertures  between  parts  which,  at  a  later  period, 
ought  to  remain  separate,  as  also  the  abiding  patency  of  certain  canals, 
namely : 

Defective  development  of  the  septa  of  the  heart's  ventricles  and  auricles; 
permanent  patency  of  the  foramen  ovale.  These  septa  form  only  gra- 
dually within  the  heart,  the  septum  of  the  auricles  not  arriving  at  its  full 
development  until  after  birth.  Defective  development  of  the  septum  of 
the  ventricles  occasions  a  resemblance  with  the  hearts  of  fishes  and  of 
reptiles  (the  crocodile  excepted),  and  especially  of  serpents  and  tortoises ; 


ANOMALIES     OF     CONNECTION.  61 

absence  of  the  septum  of  the  auricles  a  resemblance,  in  particular,  with 
the  hearts  of  fishes.  It  is  often  quite  evident  that  the  arrest  of  develop- 
ment has  been  caused  by  endocarditic  changes  in  the  valves — the  residue 
of  foetal  valvular  inflammation. 

Abiding  patency  of  the  ductus  arteriosuSj  ulterior  dilatation  thereof. 

Abiding  patency  of  the  ductus  venosus  Arantii,  giving  rise  to  the 
abduction  of  a  portion  of  blood  from  the  vena  portse  into  the  vena  cava. 

Abiding  patency  of  the  processus  vaginalis  peritoncei  (the  upper  por- 
tion of  the  tunica  vaginalis  testis),  so  commonly  the  cause  of  congenital 
hernia  or  hydro cele.  Generally  speaking,  the  inguinal  canal  closes 
immediately  after  the  testis  has,  in  the  seventh  month,  descended  into  the 
scrotal  sac,  carrying  with  it  a  process  or  continuation  of  the  peritonaeum. 
Occasionally  an  arrest  of  development  prevents  the  said  closure  from 
taking  place. 

Abiding  patency  of  the  urachus,  allowing  the  escape  of  urine  through 
the  umbilicus.  Urachus  and  urinary  bladder  are  the  portions  of  the 
allantois  internal  to  the  embryo,  which  is  destined  to  convey  the  umbili- 
cal vessels  from  the  embryo  to  the  external  membrane  of  the  ovum 
(chorion),  for  the  formation  of  the  placenta.  The  portion  of  the  allan- 
tois external  to  the  umbilicus  becomes  obliterated  at  an  early  period. 
Of  the  internal  remnant  the  inferior  portion  becomes  developed  into  the 
urinary  bladder,  whilst  the  portion  intervening  between  that  and  the 
umbilicus,  contracts  into  a  cord,  the  urachus. 

Cleft  member  (schistomelus]  commonly  appears  from  between  the  third 
and  fourth  fingers  or  toes  to  the  wrist  or  ankle.  It  is  probably  derived 
from  external  causes,  and,  as  Gurlt  infers  from  an  examination  of  the 
foetus  of  a  dog,  from  adhesion  to  the  amnion. 

2.  Malformations  through  fusion  (symphysis}.     To  these  belong: 

(<z.)  Cyclopia.  In  this  malformation  we  find  in  the  forehpad  a  single 
eye,  or  the  two  eyes  blended  into  one.  It  is  met  with  under  every  gra- 
dation of  the  fusion  of  both  eyes.  The  nose  is  either  wanting,  or  defec- 
tive, being  frequently  represented  by  an  imperforate  proboscis-like 
appendix,  which  overhangs  the  one  eye  or  the  two  united.  The  mouth 
is  sometimes  normal,  sometimes  misshapen — nay,  the  entire  infra-frontal 
countenance  may  be  wanting.  The  ethmoid,  nasal,  lachrymal,  turbinated 
bones,  the  vomer,  the  superior  maxillary  and  palatine  bones,  the  ptery- 
goid  processes,  are  often  all  or  severally  absent ;  the  anterior  lobes  of 
the  brain  invariably  so.  One  explanation  of  this  deformity  is  based 
upon  Huschke's  hypothesis,  of  both  eyes  being  developed  out  of  a  single 
primitive  rudiment,  subsequently  divided  in  twain  by  the  interposition  of 
the  nasal  and  facial  parts.  An  arrest  in  the  development  of  these  parts 
might  then,  indeed,  suffice  to  occasion  the  mischief.  Bischoff,  however, 
firmly  maintains  that  the  two  eyes  originate  at  once,  distinct  and  sepa- 
rate, from  the  anterior  primitive  brain-cell,  and  he  derives  the  cyclopian 
deformity  from  an  arrest  in  the  development  of  this  cell  causing  the  too 
close  approximation  and  eventual  fusion  of  the  rudiments  of  the  two 
eyes.  As  this  defective  development  of  the  brain-cell  frequently  causes 
a  defective  development  of  the  anterior  portion  of  the  plastic  material 
for  the  chorda  dorsalis,  and  often  for  the  anterior  process  of  the  first 


62  ANOMALIES    OF    CONNECTION. 

visceral  arch,  it  would  thus  occasion  the  absence,  before  alluded  to,  of 
the  aforesaid  facial  bones. 

(c.)  Monotia,  agnathus,  otocephalus.  The  two  ears  approach  each 
other  more  or  less  below  the  skull,  and  finally  coalesce.  The  inferior 
maxilla  is  wanting.  The  superior  maxillary,  the  zygomatic,  the  palatine 
bones,  along  with  the  pterygoid  processes,  are  either,  in  like  manner, 
wanting,  or  else  inadequately  developed.  The  mouth  is  absent  or  very 
diminutive.  The  skull  is  normal,  but  the  face  small,  and  in  brutes  pro- 
jects after  the  fashion  of  a  proboscis.  Bischoff  considers  this  deformity 
referable  to  an  arrest  of  development  of  the  first  visceral  arch,  inter- 
cepting or  impairing  the  growth  of  all  the  said  bones,  and  thus  promot- 
ing the  mutual  approximation  of  the  two  ears  beneath  the  skull.  Were 
the  internal  organs  of  hearing  implicated,  the  source  would  needs  reside 
in  a  defective  development  of  the  third  primitive  brain-cell. 

(d.)  Monopodia,  M.  Syrenomeles, — Siren-malformation.  The  two 
lower  extremities,  more  or  less  perfectly  developed  as  to  their  individual 
parts,  are  blended  into  a  single  one.  The  pelvis,  the  sexual  and  urinary 
organs,  are  wanting  or  imperfect ;  the  intestinal  canal  is  defective  beyond 
the  caecum,  and  the  anus  invariably  absent.  The  extremities,  more- 
over, have  revolved  upon  their  axes,  the  direction  of  the  patella  and  of 
the  poples  of  the  knee  being  reversed.  It  is  founded  in  a  faulty  deve- 
lopment of  the  lower  end  of  the  trunk  and  of  its  organs,  the  rudiments 
of  which  approximate  too  closely  towards  each  other,  and  ultimately 
coalesce. 

Syndactylus,  aschysto-dactylus.  Here  the  fingers  or  toes  are  imper- 
fectly separated.  It  is  an  arrest  of  development,  the  rudiment  of  hand 
and  foot,  even  when  distinctly  cognizable,  not  manifesting  at  first  any 
division  of  fingers  and  toes. 

(e.)  Fusion  of  kidneys,  testicles,  and  ovaries.  This,  according  to 
Bischoff,  is  not  due  to  arrest  of  development, — even  these  organs  not 
originating  from  a  single  rudiment, — but  rather  to  a  defective  develop- 
ment of  the  intermediate  formations  occasioning  fusion  of  the  rudiments. 

3.  Atresice. 

(a.)  Atresia  palpebrarum.  The  eyelids  are  said  to  coalesce  naturally 
towards  the  end  of  the  third  or  the  commencement  of  the  fourth  month, 
and  to  separate  afterwards.  Accordingly  this  malformation  would  be 
an  arrest  of  development. 

(b.)  Atresia  oris.  According  to  Burdach,  the  lips  coalesce  in  the 
fourth  month,  closing  the  mouth  until  the  sixth,  when  they  again  sepa- 
rate. According,  to  Bischoff,  however,  this  malformation  might  have  a 
different  origin.  At  a  very  early  period,  namely,  the  visceral  edges  of 
the  animal  layer  mutually  incline  towards  each  other  inferiorly,  unite, 
and  form,  through  the  medium  of  Rathke's  so-called  inferior  bond- 
membrane,  the  visceral  cavity  of  the  embryo.  Not  until  the  visceral 
arches  break  forth  above,  does  the  upper  portal  to  the  nutritive  canal 
open,  and  not  until  still  later  the  mouth.  The  atresy  might,  therefore, 
depend  upon  the  abiding  of  the  bond-membrane.  In  either  case  it 
would  be  an  arrest  of  development. 

(c.)  Atresia  pupillce.  Until  the  seventh  month  the  pupil  is  closed  by 
the  membrana  pupillaris,  the  anterior  section  of  a  vascular  sac  in  which 


ANOMALIES    OF    CONNECTION.  63 

the  lens,  "with  its  capsule,  is  inclosed.  Its  persistence  determines  the 
atresy. 

(d.)  Atresia  nasi.  According  to  Burdach,  the  nostril  becomes  closed 
during  the  fifth  week  by  a  saccular  plug,  which  gradually  disappears 
during  the  fifth  month.  Its  persistence  would  occasion  the  atresy. 

(e.)  Atresia  auris  externce.  The  external  meatus  auditorius  is  deve- 
loped out  of  the  posterior  upper  portion  of  the  first  visceral  fissure. 
Previously  to  birth  it  is  upon  the  whole  little  developed.  A  slight 
anomaly  of  formation  may  give  rise  to  its  closure,  although  at  no  period 
is  the  latter  normal. 

(/.)  Atresia  ani.  The  anus  is  not  present  at  first,  even  where  the 
terminal  intestine  has  formed.  A  stand-still  at  this  period,  however, 
would  involve  the  simultaneous  closure  of  the  urinary  and  sexual  organs, 
seeing  that  their  external  orifices  are  all  developed  out  of  the  primitive 
orifice  of  the  terminal  intestine, — the  cloaca.  Where,  therefore,  the 
anus  is  alone  closed,  the  mischief  must  date  from  a  later  period,  namely, 
after  the  separation  adverted  to  has  already  taken  place.  Some  phy- 
siologists believe  it  to  be,  at  a  certain  epoch,  the  natural  condition. 

(g.)  Atresia  vulvce.  Probably  conditional  upon  the  turgescent  edges 
of  the  external  orifice  of  the  uro-genital  canal  being  brought  into 
apposition,  and  coalescing  in  the  female,  as  they  ordinarily  do  only  in 
the  male  sex,  for  the  formation  of  the  scrotum.  Where  the  anus  is  at 
the  same  time  deficient,  we  have  here  again  non-development  of  the 
cloaca!  outlet. 

(h.)  Atresia  vagina,  frequently  due  to  a  preternaturally  large  hymen, 
although  occasionally  to  a  partial  deficiency  thereof,  causing  two  blind 
sacs  to  overlap  and  compress  each  other. 

(i.)  Atresia  uteri,  not  being  derivable  from  the  mode  of  development 
of  the  uterus,  is  to  be  regarded  as  a  vice  of  formation,  or  else  as  the 
result  of  inflammation. 

(Jc.)  Atresia  urethra,  in  the  male,  an  arrest  of  development, — the 
groove  at  the  nether  part  of  the  penis,  out  of  which  the  urethra  is  deve- 
loped, not  extending  to  the  glans.  In  the  fourth  month  the  glans 
becomes  perforated,  in  the  natural  course :  if  this  process  be  checked, 
this  part  will  remain  imperforate. 

To  acquired  anomalies  of  connection  belong,  firstly,  actual  interrup- 
tions of  continuity,  together  with  their  not  invariable  but  frequent  and 
obvious  associate,  diastasis, — that  is,  the  parting,  through  loosening  or 
lesion  of  continuity  of  the  binding  material  of  two  bones  immovably 
connected  together,  and  again  the  estrangement  and  deviation  of  the 
articular  ends  of  two  bones, — luxation.  Secondly,  agglutination  and 
concrescence  of  two  or  more  formations  originally  contiguous,  or  brought 
by  accident  or  design  into  mutual  association,  and  abiding  contact  with 
one  another.  Agglutination  is  effected  through  the  binding  property  of 
recently  exuded  fibrin ; — concrescence  through  the  medium  of  textures 
newly  formed  out  of  exuded  protein  substances,  and  like  unto  the 
normal  textures,  for  example,  areolar  tissue ;  or  through  the  medium  of 
such  as  differ  in  certain  respects,  for  instance,  in  the  degree  of  density 
of  aggregation, — in  the  arrangement  of  their  form-elements, — in  chemi- 
cal composition, — cancer,  for  example, — and,  lastly,  through  the  medium 


64  ANOMALIES    OF    COLOR. 

of  vessels.  This  species  of  concrescence,  in  accordance  with  the  cha- 
racter of  the  binding  material,  is  effected  by  loose,  filamentous  adhe- 
sions, admitting  of  a  certain  degree  of  motion  in  the  affected  organs ; 
or  by  tense  and  intimate  conglutinations. 

The  adhesion  of  the  parietes  of  hollow  organs,  and  the  obliteration 
of  canals  and  of  their  mouths,  represent  acquired  morbid  atresy.  This 
originates  in  various  ways :  for  example,  in  concentric  atrophy  conse- 
quent upon  deficient  expansive  power.  Thus,  in  ducts,  it  follows  the 
extinction  of  the  gland ;  in  bloodvessels,  the  cutting  off  of  the  blood 
stream ;  or  it  is  the  effect  of  abiding  compression  and  mutual  contact  of 
the  parietes ;  or,  again,  it  may  be  the  result  of  the  deposition  of 
organic  matter  out  of  the  contents  of  the  canal,  or  of  textural  changes 
in  its  walls,  produced  by  inflammation,  cicatrization,  and  the  like ;  or, 
lastly,  of  luxuriating  heterologous  growths. 

The  coalition  of  the  two  bones  in  mutual  contact  within  an  articula- 
tion is  specially  termed  articular  adhesion,  anchylosis. 


CHAPTER  VI. 

ANOMALIES  OF  COLOR. 

ANOMALIES  in  the  color  of  organs  are  either  essentially  conjoined 
with  or  independent  of  change  of  texture.  Our  concern  here  is  princi- 
pally with  the  latter  kind.  We  shall  content  ourselves  with  a  simple 
allusion  to  the  former,  as  the  true  pathological  production  of  pigment 
will  be  separately  discussed  in  the  sequel. 

The  said  anomalies  consist  in  diminution,  in  augmented  depth,  or  in 
altered  quality,  alienation,  of  color.  They  affect  the  totality,  or  simply 
the  majority  of  textures  and  organs,  or,  again,  individual  organs  only, 
or  mere  circumscribed  portions  of  these  latter.  Their  causes,  it  will 
immediately  appear,  are  numerous. 

Diminished  coloration  is  sometimes  primitive ;  various  organs,  owing 
to  an  arrest  of  development,  not  acquiring  their  natural  amount  of 
color,  a  condition  very  commonly  associated  with  the  defective  develop- 
ment of  the  organs  in  respect  both  of  texture  and  of  bulk,  as  in  the 
instance  of  muscles.  We  may  specify  a  well-known  species  of  this 
anomaly,  namely  albinoism  (leuksethiopia,  leukopathia),  wherein  the 
pigment  is  wanting  in  the  rete  mucosum  of  Malpighi,  in  the  hair,  in  the 
iris,  and  in  the  choroid  membrane  of  the  eye. 

It  is,  however,  more  frequent  as  an  acquired  morbid  condition — in  a 
word,  as  decoloration,  blanching.  Under  this  head  are  to  be  reckoned, 
firstly,  the  pallor  of  texture  consequent  upon  anaemia,  or  upon  changes 
suffered  in  various  dyscrases,  as  chlorosis,  albuminosis,  dropsy,  tabescent 
diseases,  by  those  carriers  of  coloring  matter,  the  blood-corpuscles; 
secondly,  the  blanching  of  textures  produced  by  their  maceration  in  the 
serum  of  dropsy,  by  atrophy,  by  fatty  degeneration,  the  muscles  being 


ANOMALIES     OF     COLOR.  65 


_  the  organs  principally  affected ;  lastly,  that  for  the  most  part  local, 
gradual,  or  rapid  decoloration,  due,  in  the  former  case,  to  cessation  of 
the  development  of  pigment,  in  the  latter  to  rapid  withdrawal,  or  more 
probably  to  destruction,  by  some  unknown  means,  of  the  existing  pig- 
ment. As  an  example  we  may  cite  the  topical  blanching  of  the 
common  integuments  in  colored  tribes,  in  parts  rich  in  pigment  (the 
scrotum)  in  whites,  the  progressive  or  sudden  hoariness  of  the  hair,  &c. 

Augmented  or  deepened  coloration  is,  in  certain  colored  textures,  in 
the  animal  muscles,  for  instance,  the  consequence  of  and  the  attendant 
upon  hypertrophy.  In  the  outer  integuments,  it  is  conditional  upon  the 
excessive  development  of  pigment  in  the  rete  mucosum ;  in  scars,  as  a 
purple  tint,  caused  by  the  capillary  vessels  appearing  through  the  tex- 
ture of  the  cicatrix,  in  the  embryonic  stage,  with  its  thin  layer  of  epi- 
dermis. It  is  usually  a  consequence : 

(a.)  Of  hypersemia  (congestion)  and  stasis,  more  especially  where  the 
blood  is  dark-colored,  as  in  cyanosis,  in  asphyxia,  in  a  typhous  crasis,  in 
an  inspissated  condition  of  the  blood,  consequent  upon  loss  of  serum,  &c. 

(b.)  Secondly,  of  hemorrhage,  extravasation  of  substantive  blood  into 
textures  (apoplexy) ;  sugillation  or  suffusion  founded  in  rupture,  which 
latter  may  be  the  consequence  either  of  traumatic  influences,  such  as 
contusion  and  concussion,  or  of  excessive  hypersemia,  mechanically  pro- 
duced ;  of  blood  stasis :  of  disease  of  bloodvessels ;  or  else  the  conse- 
quence of  the  patency  of  bloodvessels,  engendered  by  the  liquefaction, 
the  breaking  down  of  textures. 

(<?.)  Finally,  of  the  exudation  of  blood-serum,  with  an  appendage,  so 
to  speak,  of  blood-pigment — to  which  category  belong  ecchymosis,  pete- 
chiae  in  decomposition  of  the  blood,  in  scurvy,  in  putrid  typhus,  in  acute 
exanthematous  decomposition,  in  acute  alcohol  dyscrasis  (the  scurvy  of 
drunkards),  &c.  As  subordinate  to  this  we  may  also  mention  those  out- 
ward signs  of  death  which  assume  essentially  the  guise  of  red  coloring, 
namely,  death  patches,  death  livor,  spurious  sugillations.  Their  charac- 
ter varies : 

1.  They  are  dependent  upon  local  hypersemia  and  stasis,  brought 
about  during  the  death-struggle  and  the  period  immediately  following 
death,  as  the  consequence  of  unequable  palsy  of  the  small  and  capillary 
vessels, — whence  it  arises  that  the  blood  accumulates  in  distinct  patches 
of  the  capillary  system  various  in  extent,  whilst  in  others,  owing  to  the 
continued  contractility  of  those  vessels,  it  is  urged  onward  into  the  veins. 
Hence  they  consist  in  injection,  and,  where  the  usual  accompaniment  of 
the  livor,  from  imbibition,  is  wanting,  they  are  for  the  most  part  marked 
by  being  sharply  bounded  by  a  blanched  texture.    They  are  particularly 
frequent  in  the  mucous  membrane  of  the  intestinal  tract,  and  in  the 
lungs. 

2.  Other  death-patches  originate  after  death,  being  the  result  of  ca- 
daverous hypersemia  or  hypostasis,  which  signifies  the  descent  of  the 
blood  within  the  vessels,  conformably  with  the  laws  of  gravitation,  to 
the  most  dependent  parts.     These  patches  are  mostly  of  great  extent, 
deeply  saturated  at  their  most  dependent  parts,  and  less  and  less  so 
higher  up.     Their  seat,  answering  to  the  usually  supine  position  of  the 
dead  body,  is  the  occiput,  the  posterior  part  of  the  trunk  and  limbs ; 

VOL.  i.  5 


66  ANOMALIES    OF    COLOR. 

and  it  includes,  not  alone  the  common  integuments,  but  also  the  subcu- 
taneous soft  parts,  and  even  the  posterior  portions  of  the  viscera  con- 
tained in  the  great  cavities.  Under  different  circumstances,  they  affect 
other  regions  of  the  body ;  in  a  lateral  position  of  the  corpse,  the  nether 
lateral  half  of  the  organs — for  example,  in  hemi-lateral  hyperaemia,  the 
one  hemisphere  of  the  brain ;  in  the  prone  position  they  appear  in  the 
front;  in  those  hung  by  the  neck,  at  the  lower  half  of  the  subject  and 
internally,  in  the  organs  of  the  pelvis  and  hypogastrium. 

They  are  the  more  developed  the  greater  the  amount  of  blood  and  the 
smaller  the  degree  of  coagulation  which  the  previous  illness  and  the 
mode  of  death  have  produced  in  the  blood  during  the  mortal  struggle. 
Accordingly,  after  acute  or  chronic  decomposition  of  the  fibrine  in  the 
blood,  after  asphyxia,  they  are  especially  marked  by  their  rapid  develop- 
ment after  death,  by  their  extent,  and  by  their  depth  of  color. 

3.  A  third  species  of  death-marks  arises  from  the  imbibition,  by  the 
coats  of  bloodvessels,  and  the  transuding  from  thence  into  the  neighbor- 
ing tissues,  of  blood-serum,  which,  owing  to  decomposition,  has  taken  up 
a  portion  of  the  pigment  of  the  blood-globules.  In  this  manner  are  pro- 
duced the  livid  striae  which  follow  the  course  of  the  subcutaneous  veins 
in  the  common  integuments,  the  red  coloration  of  the  endocardium,  and 
of  the  internal  membranous  strata  of  the  vascular  trunks,  the  diffuse 
reddening  of  serous  and  mucous  membranes,  the  red  tinge  observed  in 
parenchymata  and  seemingly  inherent  in  their  textures.  Not  only  does 
imbibition  pass  from  one  organ  to  others  contiguous, — even  fluids,  con- 
tained within  hollow  organs,  as  also  in  muco-membranous  canals  and  in 
serous  sacs,  receive  the  blood-tinged  serum,  thereby  acquiring  the  same 
cadaverous  hue ;  or,  again,  the  blood-tinged  serum  is  found  in  the  said 
cavities,  pure,  and  unmingled  with  pre-existing  fluids  in  the  form  of 
cadaverous  exudations. 

The  reddening  of  imbibition  is,  of  course,  most  readily  derived  from 
vessels,  the  seat  of  hypersemia  and  of  stasis ;  therefore  very  commonly 
from  the  death-patches  of  the  two  species  above  named.  The  redness  of 
injection  characteristic  of  hypersemia  and  stasis  merges  in,  or  becomes 
masked  and  disguised  by,  that  of  imbibition. 

Death-spots  of  this  kind  are  marked  by  absence  of  injection ;  by  the 
obvious  cause,  namely,  blood  being  discoverable  at  the  point  of  the  deep- 
est saturation,  and  by  the  stain  being  washed  out  towards  the  circumference. 

Where  the  previous  disease  involves  liquefaction  of  the  blood-plasma — 
they  are  rapidly  developed,  and  they  increase  in  saturation  and  extent  in 
proportion  as,  favored  by  various  external  influences,  cadaverous  decom- 
position gains  ground. 

It  would  appear,  from  the  above,  that  death-spots  are,  for  the  most 
part,  stains  resulting  from  a  combination  of  hypersemia  with  imbibition. 

Amongst  the  number  of  imbibition  stains,  with  the  character  of  death- 
marks,  is  to  be  reckoned  the  yellow  tinge  imparted  to  the  membranes  of 
the  gall-bladder  and  of  the  adjacent  membranes  of  the  stomach  and  in- 
testine by  the  imbibition  of  bile. 

To  qualitative  alienations  of  color  belong  more  especially,  as  cadaveric 
stains  subordinate  to  the  above — 

1.  The  original  changes  of  tone  in  death-stains  to  blue,  purple,  and 
violet,  dependent  upon  the  blood-crasis. 


ANOMALIES     OF     COLOR.  67 

ie  brownish  and  greenish  tints,  and  the  dark  green  dye  developed 
out  of  the  reddening  of  imbibition,  both  in  the  common  integuments  and 
in  other  soft  parts,  as  also  in  an  especial  manner  in  the  intestinal  mem- 
branes and  their  contiguous  formations — namely,  the  peritoneum,  the 
areolar,  adipose,  and  muscular  tissues,  and  the  liver.  These  varieties  of 
color  are  produced  by  certain  gases — hydrosulphuric  acid  and  sulphide 
of  ammonia, — evolved  in  the  abdominal  cavity,  and  within  the  tissues 
themselves.  These  gases  react  thus  upon  the  red  pigment  of  the  blood 
within  the  tissues  generally,  and  in  the  muscles  most  of  all. 

3.  The  dark  brown,  black,  green,  and  ink-black  discoloration  of  the 
spleen,  from  its  fissured  surface  to  various  depths,  as  also  of  the  ramifi- 
cation of  bloodvessels  in  the  fluid  sac  of  the  stomach  from  the  imbibition 
of  gastric  juice. 

4.  The  more  rare  violet-red,  iodine-colored,  diffuse  lividity  of  the  intes- 
tinal membranes. 

Other  preternatural  colorations,  for  the  most  part  equally  cognizable 
in  the  living  body,  are,  in  particular — 

1.  The  deep  red  tinge  characteristic  of  thin  watery  blood,  as  also  of 
all  the  tissues,  down  to  the  common  integuments,  in  cases  of  poisoning 
with  carbonic  oxide  and  carbonic  acid  gas. 

2.  The  copper-red  tint  of  the  skin  in  venereal  stains,  and  in  the  cir- 
cumference of  venereal  ulcers  and  skin  eruptions. 

3.  The  diffuse  sallowness,  and  the  circumscribed  freckle-spots,  termed 
liver-stains  or  ephelides,  in  cachexia. 

4.  The  violet  hue  of  typhous  hypersemia  and  stasis. 

5.  The  greenish  and  yellowish  tones  of  sugillation  of  the  common  in- 
teguments, arising  from  deep-seated  extravasation  of  blood. 

6.  The  yellow  tinge  of  the  solids  and  fluids,  assuming  manifold  shades, 
the  most  intense  of  which  are  a  brazen-  and  a  greenish-yellow,  engendered 
by  the  coloring  matter  of  the  bile,  where  the  secretion  and  excretion  of 
that  fluid  are  intercepted,  or  where  bile  mingles  with  the  blood,  as  in  the 
typhous  crasis.     It  is  frequently  superinduced  by  pyaemia,  and  occurs 
as  the  substantive  and  essential  dyscrasy  in  yellow  atrophy  of  the  liver, 
and  probably  in  yellow  fever.     As  this  pigment  generally  associates 
itself  with  the  exsuding  plasma,  the  majority  of  the  soft  parts,  more 
especially  the  vascular  and  succulent — the  secretions  and  incidental  pro- 
ducts of  inflammation — are  all  dyed  yellow. 

7.  The  rust-yellow,  rust-brown,  black-brown,  and  black  tints  of  cer- 
tain organs,  resulting  from  a  corresponding  granular  pigment,  partly 
contained  within  pigment-cells — a  formation,  which  will,  in  the  sequel, 
be  considered  more  at  large. 

8.  In  conclusion,  those  anomalous  dyes,  produced  by  the  assimilation 
of  pigments,  or  of  substances  which,  either  with  or  without  the  interven- 
tion of  some  specific  influence — light,  for  example — enter  into  peculiarly 
tinged  combinations  with  animal  tissues.     As  instances  of  the  decolora- 
tion of  both  fluids  and  solids,  we  may  cite  the  yellow  appearance  of  the 
urine  from  the  ingestion  of  rhubarb,  the  reddening  of  the  bones  from 
feeding  upon  the  root  of  rubia  tinctorum,  the  yellowness  of  the  skin  and 
of  the  mucous  membranes   produced  by  nitric  acid,  the  swarthy  com- 
plexion which  follows  the  internal  use  of  nitrate  of  silver. 


68  ANOMALIES    OF    CONSISTENCE. 

CHAPTER  VII. 

ANOMALIES  OF  CONSISTENCE. 

CONSISTENCE  [the  normal  degree  of  mutual  cohesion  and  of  resisting 
power  pertaining  to  the  elements  constituting  a  texture]  is  either  aug- 
mented or  diminished.  In  either  case  the  gradations  and  also  the  forms 
vary  greatly,  cannot  be  estimated  but  in  relation  to  the  amount  of 
mechanical  violence  exerted,  and  exist,  to  a  certain  extent,  in  combina- 
tion with  each  other. 

Diminution  of  consistence  is  based  upon — 

1.  Loosening  of  the  mutual  cohesion  between  the  form-elements  com- 
posing a  texture,  through  the  interposition  of  a  fluid  or  solidified  sub- 
stance.    Instances  are  afforded   in  the  loosening  of   texture   through 
serous  effusion  (dropsy),  and,  in  hypersemia  and  inflammation,  through 
their  products.     Such  loosening  of  texture  is  generally  considerable  in 
proportion  to  the  rapidity  with  which  the  said  products  form. 

2.  Atrophy,  both  primary  and  secondary,  provided  the  density  of  the 
texture  be  diminished.  „ 

3.  Liquefaction  and  breaking  down  of  the  elementary  forms  of  the 
texture,  as  in  suppuration,  in  gangrene,  but  most  especially  and  most 
variously  in  liquid  exudation  from  mucous  membranes,  which  by   its 
chemical  properties  proves  destructive  to  the  underlayer.     Liquefaction 
of  the  substance  of  the  liver,  through  anomalous  or  intercepted  bile, 
offers  another  instance  in  point. 

4.  Next  to  these  rank  the  softenings  of  certain  organs,  particularly 
of  the  mucous  membrane  lining  the   stomach,  of  the  lungs,  and  of  the 
brain,  brought  about  by  the  resolvent  agency  upon  the  textures  of  a  free 
acid.     They  represent  those  processes  to  which,  in  conjunction,  perhaps, 
with  the  foregoing,  the  term  softening  ought  properly  to  be  restricted. 

The  abstraction  of  earthy  salts  from  the  bones,  in  rickets  and  osteo- 
malacia,  belongs  to  this  class. 

5.  It  is  brought  about  by  a  transformation  of  textures,  the  nature  of 
which  is  most  probably  a  breaking  up,  with  conversion  of  the  chemical 
constituents ; — for  example,  the  breaking  up  of  the  primitive  muscular 
fibrils,  or  of  the  texture  of  the  annulo-fibrous  tunic  of  the  arteries,  in 
fatty  degeneration. 

Diminished  consistency  manifests  itself  as  irregular  softening,  com- 
pressibility, lacerability,  maceration,  liquefaction,  and  solution ;  or  else 
as  pulpiness,  putrescence,  friability,  fragility — the  latter  property  being 
frequent  in  the  osseous  system,  in  muscles,  and  in  the  annulo-fibrous 
tunic  of  the  arteries. 

Increase  of  consistence  varies,  in  like  manner,  as  to  its  character  and 
cause.  It  is  based — 

1.  Upon  diminution  of  the  humecting  plasma,  by  which  the  texture  is 
pervaded  (water). 

2.  Upon  hypertrophy.     Those  augmentations  of  consistence  are  par- 


SEPARATIONS    OF    CONTINUITY.  69 


ticularly  marked  which  depend  upon  true  hypertrophy  without  increase 
of  volume,  and  upon  various  kinds  of  spurious  hypertrophy. 

3.  Upon  atrophy,  the  reduction  of  volume  being  here  accompanied  by 
condensation, — concentrical  hypertrophy, — of  the  brain,  for  instance. 

4.  Upon  inflammation, — through  the  solidification  and  textural  trans- 
formation of  coagulable  products ; — in  other  words,  by  the  issue  of  the 
inflammation  in  induration. 

5.  Upon  what  is  termed  ossification,  so  common  in  the  aforesaid  pro- 
ducts of  inflammation. 

Increase  of  consistence  manifests  itself  as  preternatural  toughness, 
hardness,  rigidity.  Relatively  to  the  normal  condition  of  the  textures, 
it  often  appears  less  in  the  shape  of  absolute  increase,  than  of  a  change 
in  the  character  of  the  consistence.  Thus  the  friable  liver,  the  kidneys, 
under  certain  conditions,  in  spansemia,  for  example,  toughen  through 
defibrination  of  the  sanguineous  fluid.  The  increase  of  consistence  is 
often,  moreover,  but  a  seeming  one,  and  even  such  only  with  certain  re- 
strictions. Thus  the  organ  concerned  will  exercise,  against  ordinary 
external  influences,  a  resistance  exceeding  the  natural,  and  yet  be  power- 
less against  more  forcible  impressions,  because,  although  with  increased 
density  it  has  become  harder  and  firmer,  it  has  at  the  same  time  lost  its 
toughness,  and  become  morbidly  fragile  and  brittle.  Muscle  affords  an 
example. 


CHAPTER  VIII. 

SEPARATIONS  OF  CONTINUITY. 

THEY  are  engendered  either  by  external  and  especially  by  mechanical 
influences,  or  else  by  various  internal  causes  which  may,  in  like  manner, 
operate  mechanically. 

To  the  former  belong : 

1.  Simple  or  complicated  injuries  from  penetrating  mechanical  vio- 
lence, with  or  without  loss  of  substance ; — incised,  punctured,  contused, 
gunshot,  bitten,  and  lacerated  wounds ; — solutions  of  continuity  occa- 
sioned by  fire  and  cautery. 

2.  Imperfect  and  complete  laceration  and  rupture  of  solid  as  also  of 
hollow  organs,  consequent  upon  concussive  violence, — especially  when  in 
the  condition  of  repletion  and  of  distension, — lesions  of  continuity  fre- 
quently unaccompanied  by  perceptible  injury  to  the  common  integu- 
ments and  to  the  parietes  of  the  implicated  cavities  of  the  body.     The 
casting  of  the  envelopes  of  particular  organs  caused  by  similar  violence, 
as  the  separation  of  periosteum,  of  the  dura  mater,  from  bone,  of  the 
fibrous  capsules  (tunicae  albuginese)  of  certain  viscera,  as  of  the  spleen  or 
kidneys, — is  of  like  significance. 

3.  Simple  and  complicated  fractures  of  bones,  incurvation  of  soft, 
rickety  bones,  casting  of  the  epiphyses. 

Separations  of  continuity  from  internal  causes  are  dependent  upon 


70  ANOMALIES    OF    TEXTURE. 

various  contingencies.  Where  mechanical  influence  is  simultaneously  at 
work,  the  two  influences  co-operate  in  such  wise  that  where  the  one  pre- 
dominates, less  of  the  other  suffices  to  produce  the  effect.  Their  occur- 
rence may  be  rapid  or  slow.  They  are  brought  about — 

1.  By  violent  exercise  of  the   voluntary  and  involuntary  muscles, 
lacerating  either  these  or  their  tendons,  or  even  affecting  the  bones, — 
in  convulsions,  for  instance. 

2.  By  excessive  distensions  of  hollow  organs,  as  in  laceration  of  the 
intestine,   of  the  urinary  bladder   from   accumulation   of  its   contents 
through  paralysis,  through  mechanical  obstruction,  stricture,  closure,  &c. 

3.  By  hemorrhage.     Here  the  lesio  continui  consists  in  great  lacera- 
tion,  contusion,   disruption,  destruction  of  texture  ;  take,  for  example, 
apoplexy  of  the  brain,  of  the  liver,  of  the  muscles ;  the  forcible  separa- 
tion of  the  strata  composing  a  membranous  organ ;  the  loosening  of  the 
enveloping  membrane  of  organs,  of  the  periosteum  from  bone,  of  the 
tunica  albuginea,  through  extravasated  blood. 

4.  By  atrophy.     When  favored  by  a  mechanical  influence  it  occasions 
a  rapid  lesion  of  continuity  in  the  shape  of  laceration, — or  else,  being 
itself  caused  by  pressure  and  tension,  it  serves  in  the  long  run  to  pro- 
duce lesion  of  continuity,  more  especially  in  the  muscles  and  nerves. 
Under  this  head  should  be  mentioned  the  spontaneous  casting  of  normal 
and  of  morbid  formations,  owing  to  defective  nutrition,  as  of  the  hair, 
the  nails,  the  teeth,  horny  excrescences,  and  the  like. 

5.  Separation  of  continuity  is  the  final  result  of  high  degrees  of 
diminution  of  consistency,  especially  in  true  softening,  the  consequence 
of  textural  disease.     If,  therefore,  any  mechanical  cause  be  requisite  at 
all,  the  slightest, — even  the  degree  ordinarily  in  operation,  as  for  exam- 
ple, repletion  of  a  hollow  organ,  suffices  to  produce  the  effect.     Amongst 
textural   diseases,  inflammation — from   its    effects   in   the   loosening  of 
tissues, — and  the  fatty  degeneration  of  muscular  organs,  more  especially 
of  the  annulo-fibrous  tunic  of  arteries — stand  pre-eminent. 

f6.  In  fine,  lesions  of  continuity  are  engendered  in  primary  textures, 
as  well  as  in  new  growths,  by  various  processes  of  liquefaction  and  disso- 
lution, especially  by  suppuration  and  gangrene.  To  this  head  belongs, 
amongst  others,  the  spontaneous  separation  of  dead  parts,  for  instance  of 
fingers,  of  entire  limbs,  of  heterologous  products,  such  as  fibroid  and 
cancerous  growths.  Lesions  of  continuity  are,  upon  the  whole,  simple, 
or  else  more  or  less  associated  with  loss  of  substance.  Their  cure  is 
effected  by  the  immediate  union  of  the  edges  or  surfaces  of  the  wound, 
or,  in  the  case  last  alluded  to,  by  regeneration. 


CHAPTER  IX. 

ANOMALIES   OF   TEXTURE. 

THESE  are  the  most  important  of  all.     They  affect  the  solids  and  the 
fluids,  especially  the  blood,  in  so  far  as  certain  form-elements  enter  as 


ANOMALIES     OF    TEXTURE.  71 


essential  ingredients  into  its  composition,  and  so  far  as  this  general 
source  of  nutrition,  under  particular  circumstances,  contains  and  supplies 
formative  matter  anomalous  in  many  respects  as  to  its  embryonic  cha- 
racter and  primitive  forms,  and  also  as  to  all  its  ulterior  stages  of  deve- 
lopment. They  are  commonly  connected,  in  the  relation  either  of  cause 
or  of  effect,  with  various  other  of  the  anomalies  of  volume,  of  consistence, 
of  form  and  of  color  already  discussed. 

Every  change  of  texture  being  founded  in  an  anomaly  of  general  nu- 
trition, the  proximate  causes  of  this  anomaly  have  to  be  investigated. 

As  such  are  directly  demonstrable  or  at  least  deducible  from  analogy, 
— alterations  of  the  blood,  as  the  general  fluid  of  nutrition,  and  anoma- 
lous character  of  the  nutritive  process  itself.  Accordingly,  textural 
disease  of  the  solids  is  in  the  one  case  the  reflex  of  constitutional  disease, 
in  the  other  case  a  mere  local  ailment. 

Quantitative  anomalies  of  nutrition  having  been  considered  under  the 
heads  of  hypertrophy  and  atrophy,  the  present  chapter  will  comprise 
those  textural  diseases  alone  which  depend  upon  qualitative  anomalies  of 
nutrition. 

Textural  diseases  may  be  primitive  arrests  in  the  development  of  the 
texture — for  example,  in  bones,  in  muscles,  in  pigment, — such  as  we  may 
observe  at  any  time  in  tissues  adapted  for  regeneration.  The  majority 
are,  however,  acquired  during  intra-uterine,  and  more  especially  during 
extra-uterine  life.  In  the  former  case  the  textural  anomaly  is  con- 
genital. 

Textural  anomalies  manifest  themselves — 

1.  As  new  groivtlis.     The  most  numerous  of  the  class. 

2.  As  a  breaking  down  of  texture.     The  disruption  involves  both  the 
primitive  physiological  and  the  new-formed  pathological  texture, — the 
latter,  by  their  frequent  persistence,  at  the  embryonic  stage  of  textural 
development,  or  even  in  the  condition  of  the  primitive  rude  blastema, 
are  particularly  predisposed  to  this  sort  of  conversion  of  their  elements. 
To  this  subdivision  belong,  besides  the  reduction  of  textures  in  atrophy — 
besides  the  breaking  up  of  textures  in  genuine  softening,  in  particular 
the  liquefaction  of  textures  in  various  processes  of  exudation,  in  suppu- 
ration, and  in  gangrene.     And  to  these  are  yet  to  be  added  other  pro- 
cesses which  seem  to  be  conversions  of  various  complex  substances  con- 
stituting, now  a  rude  blastema,  now  a  definite  texture, — the  breaking 
up  of  fibrinous,  albuminous  blastemata,  of  muscular  fibrils,  of  yellow 
artery-fibres,  with  conversion  of  their  elements  into  fat,  &c.     They  will 
be  considered,  together  with  their  attendant  circumstances,  under  the 
heads  partly  of  general,  partly  of  special  anatomy. 

New  growths,  as  already  observed,  furnish  forth  the  great  majority 
of  textural  affections.  For,  apart  from  their  mere  local  characters, 
almost  all  constitutional  diseases  are  prone  to  localization  and  to  the 
deposition,  within  an  area  more  or  less  defined,  of  products  in  the  shape 
of  blastemata.  Even  the  processes  of  liquefaction  are  in  part  ultimately 
reducible  to  a  new  growth,  for  example,  to  an  exudation  destructive  of 
the  texture,  to  the  production  of  acid,  &c.  Textural  diseases  assuming 
the  shape  of  new  growths  were  formerly  distinguished  in  a  manner  which 
here  calls  for  a  few  remarks.  Pathologists  discriminated  between  : 


72  ORGANIZED  NEW  GROWTHS. 

1.  Changes  (metamorphoses)  of  textures.  / 

2.  Genuine  new  or  heterologous  growths. 

With  reference  to  this  distinction  which,  before  the  adoption  of  the 
present  auxiliary  methods  of  research  was  highly  estimated,  we  have  to 
observe  that,  strictly  speaking,  the  conversion  of  one  texture  into  an- 
other only  occurs  in  isolated  instances,  which  will  be  hereafter  specified. 
With  these  exceptions,  all  conversions  are  but  seeming  ones,  and  consist 
in  the  anomalous  growth  becoming  developed  betwixt  the  elementary 
particles  and  filling  up  the  interstices  of  the  original  normal  texture,  so 
as  to  occasion  the  reduction  and  resorption  of  the  latter. 

This  process  of  reduction  and  absorption  may  be  so  complete  as  ulti- 
mately to  cause  the  original  texture  to  be  altogether  replaced  by  the 
new  growth,  which  now  presents  one  uniform  mass,  corresponding  in 
volume  with  the  texture  expelled,  or  even  exceeding  it, — in  a  word, 
constituting  a  tumor. 

But  although  this  process  apparently  disproves  any  conversion,  it  still 
remains  matter  for  inquiry  whether,  in  a  certain  sense,  a  conversion  do 
not  take  place, — whether  the  original  but  reduced  texture  do  not,  under 
the  determining  influence  of  the  heterologous  development,  furnish  the 
blastema  for  the  new  growth?  Several  circumstances  afford  decisive 
evidence  of  a  metamorphosis  of  this  kind. 

As  true  conversions  are  to  be  regarded — 

(a.)  The  ossification  of  cartilages  intended  for  permanent  ones ;  as 
also  of  pathological  cartilage — of  certain  euchondromata.  Again 

(5.)  The  fibrillation  of  the  hyaline  intercellular  substance  of  cartilage. 

(c.)  A  metamorphosis  of  muscular  fibre  into  areolar  fibrils,  such  as 
takes  place,  in  the  organic  muscles  obviously  through  a  splitting  of  the 
muscle  fibres, — in  the  animal  muscles,  probably  through  fibrillation  of 
the  collapsed  sheaths  of  the  primitive  muscle  fibres,  after  the  breaking 
up  and  resorption  of  their  contents  (the  primitive  fibrils). 

(d.)  A  transformation  of  the  organic  muscle-fibres  into  the  annulo- 
fibrous  membrane-texture  of  arteries. 

(e.)  A  transformation  of  primitive  muscle-fibrils,  of  the  fibrous  web 
upon  the  layers  constituting  the  annulo-fibrous  membrane-texture  of 
arteries,  into  free  fat  (see  fatty  degeneration).  We  are  not  indisposed 
to  believe  in  a  conversion  of  hepatic  cells  into  the  elementary  cells  of 
medullary  cancer. 

Let  us,  after  this  disquisition,  turn  to  the  division  of  new  growths  : 

1.  Into  organized  and  organizable  new  growths. 

2.  Into  unorganized  new  growths. 

I.   ORGANIZED  NEW  GROWTHS. 
A.    OF  ORGANIZED  NEW  GROWTHS  IN  GENERAL. 

These  resemble  normal  textures,  at  least  in  their  elementary  compo- 
sition,— and  very  frequently  in  the  (secondary)  arrangement  of  their 
form-elements.  Where  they  appear  amorphous,  the  character  of  the 
blastema  attaches  to  such  amorphous  growths.  They  are  occasionally 
united  with  unorganized  new  formations,  and  that  commonly  in  a  con- 


ORGANIZED     NEW     GROWTHS. 


73 


secutive  manner,  the  latter  supervening  upon  the  new  growth,  as  in  the 
instance  of  so-termed  ossification  in  the  shape  of  concretion  or  incrus- 
tation. 

New  growths  present  great  and  important  differences  in  relation  not 
alone  to  the  form-elements — especially  cell  and  fibre, — but  also  to  the 
secondary  arrangement  of  these  elements  into  a  texture. 

Nor  do  they  differ  less  widely  and  essentially  as  to  origin  and  deve- 
lopment. In  this  respect  they  often,  it  is  true,  follow  the  laws  of  cell- 
formation — cytoblastema,  elementary  granule,  nucleus,  cell,  fibre.  The 
field,  however,  is  equally  extensive  of  fibrillation  out  of  nuclei  and 
granules,  and  especially  that  of  the  independent  development  of  fibre 
directly  out  of  solid  blasternata,  intercellular  substance,  primitive  struc- 
tureless membrane,  and  membranaceous  coagula.  Compare,  with  re- 
ference to  this  and  to  what  next  follows,  Blastemata. 

With  reference  to  the  grade  of  development  attained  by  their  elements, 
new  growths  are  classed,  if  such  a  classification  be  feasible,  considering 
the  variety  of  elementary  bases  coexisting  in  a  single  growth,  and  the 
want  of  uniformity  in  their  ulterior  development,  as  follows : 

1.  Such  as  exist  in  the  condition  of  formless  liquid,  or  at  that  phase 
of  coagulation — the  consolidating  blastema.     They  are   susceptible  of 
further  development,  or  they  abide  at  this  stage,  many  ultimately  break- 
ing up.    They  comprise  some  very  malignant  new  growths — for  example, 
tubercle. 

2.  Such  as  attain  to  nucleus  and  cell-formation  only, — perhaps  to 
fibre  or  caudate  cells.     They  consist  of  isolated  cells  within  a  fluid,  semi- 
fluid, intercellular  substance  (pus ;  colloid,  encephaloid  substance) ;  or, 
again,  the  cells  are  imbedded  in  a  paucity  of  firmer,  amorphous  inter- 
cellular substance,  which  acts  as  a  bond-mass.     Along  with  them  are 
numerous  nuclei  and  elementary  granules — embryonic  formations  readily 
broken  up.     Some  of  the  most  malignant  new  growths  are  thus  con- 
stituted. 

3.  Such  as  have  their  texture  represented  by  fibres  of  different  kinds, 
variously  arranged,  and  arising  out  of  cells,  nuclei,  elementary  granules, 
or  directly  out  of  blastema.     To  this  class  belong  many  quite  benign, 
and  a  few  eminently  malignant  formations :  for  example,  fibrous  cancer. 

4.  New  growths,  which,  in  their  full  development,  consist  of  fibres, 
cells,  nuclei,  blastema,  although  the  disposition  and  the  mode  of  develop- 
ment of  these  elements  may  greatly  vary.     They  include  new  forma- 
tions, both  benign  and  the  reverse.     The  progressive  development  of  the 
form-elements   is    accompanied   by  a   succession   of  chemical  changes. 
Under  every  mode  of  development  the  reactions  vary  with  every  phase, 
from  the  primitive  blastema  to  the  completion  of  a  texture,  the  difference 
between  the  perfect  texture  and  the  primitive  blastema  being  very  marked 
indeed. 

With  reference  to  the  development  of  bloodvessels,  new  growths  are 
either  vascular  or  non-vascular.  The  former  present  every  gradation, 
from  poverty  in  bloodvessels  to  luxuriant  vascularity.  Nor  does  the 
number  of  its  bloodvessels  stand  in  any  direct  relation  either  to  the  bulk 
or  volume  of  the  new  growth,  or  to  the  stage  of  its  development  in  other 
respects.  Accordingly,  there  are,  on  the  one  side,  new  formations  of 


74  ORGANIZED  NEW  GROWTHS. 

very  considerable  magnitude,  which,  devoid  of  all  bloodvessels,  vegetate 
freely  in  the  cavities  of  the  body — for  example,  the  frequent  fibroid  con- 
cretions in  serous  cavities,  certain  cancers,  &c.  On  the  other  side,  there 
are  blastems  in  which  blood  and  bloodvessel-formation  so  predominate 
that  the  new  growth  consists  of  little  else.  (See  Pathological  Blood- 
vessel-Formation. ) 

With  reference  to  their  state  of  aggregation,  new  formations  are  either 
fluid  or  semifluid, — for  example,  the  plasma  containing  dropsical  fluids, 
pus,  ichor,  encephaloid  fluid,-  colloid,  the  gelatinous  substance  of  col- 
lonenia,  of  areolar  cancer,  &c.,  or  they  are  solid. 

Not  long  since  there  existed  a  classification  of  new  growths,  which, 
though  not  altogether  available,  is  nevertheless  deserving  of  mention — 
namely,  their  division  into  homoeoplasice  and  heteroplasice.  The  former 
(according  to  the  earlier  views  of  Meckel)  are  repetitions  or  imitations 
of  normal  textures,  the  latter  alien  to  the  normal  composition  of  the 
organs  and  textures.  With  respect  to  this  division,  it  is  to  be  observed, 
that : 

(a.)  The  chief  argument  against  the  assumption  of  heteroplasise  is 
afforded  in  the  evidence  recently  obtained,  that  all  new  growths  essen- 
tially imitate  normal  formations,  not  alone  in  their  origin,  development, 
and  growth,  but  also  in  their  chemical  composition. 

(b.)  Even  the  secondary  arrangement  of  their  textural  elements,  that 
is,  their  coarser  texture,  very  frequently  offers  analogies  with  normal 
textures.  Finally,  their  general  aspect  exhibits  to  the  naked  eye  analo- 
gies which  formerly  served  for  the  basis  of  certain  classifications  and 
denominations.  Take  for  example  the  comparisons  with  various  glandular 
structures  made  by  Abernethy  and  others. 

(c.)  It  might  appear  from  the  above,  that  homoeoplasise  alone  existed. 
Still,  in  many  heterologous  formations  the  external  aspect,  the  structure, 
and  even  the  textural  elements,  especially  cell  and  fibre,  differ,  not  only 
in  themselves,  but  in  the  progress  of  their  development  and  in  their 
chemical  composition,  so  materially  from  the  normal  type,  that  the  exist- 
ence of  heteroplasise  cannot  be  altogether  rejected.  As  regards  the  rela- 
tion of  new  growths  to  normal  texture,  it  should  be  stated  that, 

1.  The  heterologous  formation  lodges  more  or  less  uniformly  between 
the  elementary  parts  of  a  texture,  the  latter  becoming  infiltrated.     The 
mass   (and  commonly  the  volume  also)   of  the  organ  increases — false 
hypertrophy. 

2.  Where,  on  the  other  hand,  the  heterologous  formation  is  developed 
and  increases  from  an  interstitial  point,  or  even  from  an  originally  cir- 
cumscribed infiltration,  so  that  at  its  circumference  it  rather  displaces 
than  involves  or  embraces  the  elements  of  the  affected  organ,  and  so 
that  its  periphery  becomes  more  or  less  sharply  defined,  it  forms  an 
individual  independent  heterologous  mass,  termed  a  tumor. 

The  distinctive  characters  of  the  two  are,  however,  by  no  means 
strongly  marked.  Akin  to  the  above  division  is  another,  almost  essen- 
tial to  the  medical  practitioner,  however  little  tenable  in  a  scientific  point 
of  view,  namely,  into  benign  and  malignant  new  growths  (benign  and 
malignant  tumors).  The  connection  between  the  two  classifications 
consists  in  this,  that,  with  certain  exceptions,  homoeoplasioe  appear  to 


ORGANIZED    NEW    GROWTHS.  75 

and  actually  do  answer  to  the  character  of  benign,  whilst  a  grade  of 
malignancy  may  be  predicated  of  a  new  growth  proportionate  to  the 
degree  of  its  heterogeneous  nature.  In  this  classification  it  is  essential 
to  determine, 

1.  What  constitutes  a  benign,  what  a  malignant  new  growth  ? 

2.  What  are  the  distinctive  marks  of  the  one  and  the  other  ? 

In  the  first  place,  we  would  signify  by  malignant  new  growths,  those 
the  origin  and  continuance  of  which  either  are  essentially  bound  up  with, 
or  else  eventually  lead  to,  a  definite  constitutional  dyscrasis,  a  general 
disease  giving  rise  to  a  peculiar  impairment  of  nutrition,  and  a  multipli- 
cation of  specific  new  growths.  No  new  formation  is,  therefore,  in  itself 
malignant,  but  becomes  so  either  through  a  specific,  pre-existent,  and 
predetermining,  or  through  a  consecutive,  general  dyscrasial  affection. 
This  is  perhaps  the  proper  explanation  of  a  malignant  new  growth.  It 
does  not  preclude  that  occasional  purely  local  relation  of  a  malignant 
formation  upon  which  the  cure  of  the  latter,  spontaneous  or  artificial, 
often  depends.  It  will  be  seen  that  whatever  else  is  adduced  as  an 
attribute  of  malignant  tumors  ceases  to  be  distinctive. 

(a.)  It  is  very  difficult  to  recognize  a  constitutional  disease  as  a 
definite  one  reflected  in  a  new  growth,  and  to  discriminate  between  this 
and  a  cachexia  engendered  by  the  luxuriation  and  ichorous  vent  of  a 
new  growth  essentially  local,  and  pronounced  benign.  Besides,  the  con- 
stitutional affection  may  as  yet  be  altogether  wanting.  Even  where 
several  growths  coexist  of  the  same  character,  or  rapidly  succeed  each 
other,  they  need  not  necessarily  be  based  upon  any  general  dyscrasis. 
They  may  be  simply  so  many  mere  local  occurrences. 

Certain  other  characteristics  are  indispensable  for  a  diagnosis,  and,  at 
the  same  time,  difficult  to  establish :  for  example,  that — 

(b.)  Benign  growths  are  curable  by  extirpation,  whilst  the  malignant 
recur  at  the  same  spot,  or  at  other  spots,  or  even  at  both. 

In  opposition  to  this,  it  is  to  be  urged,  that  many  benignant  new 
growths  recur  after  extirpation,  where  the  disposition  to  them  remains, 
whilst,  under  certain  conditions,  many  a  malignant  new  growth  does  not 
recur,  but  enters  upon  a  spontaneous  process  of  retrogression,  and 
becomes  extinct. 

(c.)  Malignant  new  growths  have  a  marked  tendency  to  draw  within 
their  formative  range — to  convert  to  their  own  similitude — contiguous 
and  neighboring  textures. 

It  is  to  be  observed,  on  the  other  hand,  first,  that  the  most  malignant 
growths  thrive  and  flourish  as  independent  tumors  upon  a  new-formed 
vascular  apparatus  of  their  own,  without  otherwise  molesting  the  sur- 
rounding textures  than  by  forcing  them  from  their  positions  ;  secondly, 
that  where  the  original  normal  textures  merge  in  the  heterologous 
growth,  this  is  brought  about  in  the  malignant,  precisely  as  it  is  in  the 
benignant  ones — namely,  by  a  conversion  in  the  sense  before  adverted 
to ;  that  is,  through  reduction,  disintegration,  and  resorption  of  the 
normal  textural  elements. 

(d.)  When  malignant  growths  have  attained  their  highest  point  of  de- 
velopment, they  break  up  and  enter  upon  a  process  of  softening,  which 


76  ORGANIZED  NEW  GROWTHS. 

implicates  or  involves  surrounding  and  included  textures,  and  thus  serves 
to  exhaust  the  organism. 

In  connection  with  this  process,  the  following  subjects  for  consideration 
suggest  themselves :  namely, 

1st.  This  so-called  stage  of  metamorphosis — this  breaking  up  very 
frequently  fails  to  occur,  even  in  the  most  malignant  new  growths. 

2d.  That  apart  from  the  general  difficulty  of  establishing  the  epoch  of 
the  highest  development  of  a  new  formation,  the  act  of  breaking  up 
should  seem  a  fortunate  event  as  regards  the  growth  itself,  which,  by 
virtue  of  the  elementary  transformations  thereby  engendered,  becomes 
deprived  of  its  importance,  and  in  many  instances  is  excreted  from  the 
body. 

3d.  That  this  metamorphosis  for  the  most  part  simply  implies  inflam- 
mation terminating  in  ichorous  degeneration,  and  death  of  the  new  growth. 
4th.  That  this  destructive  process  frequently  attacks  the  surrounding 
textures  merely  in  the  character  of  suppuration,  and  that,  as  such,  it  may, 
whether  based  upon  a  benignant  or  upon  a  malignant  new  formation, 
either  exhaust  the  organism,  or,  on  the  contrary,  lead  to  a  cure, — to  the 
expulsion  of  the  heterologous  product. 

5th.  That  where  a  fresh  development  of  heterologous  substance  is 
excited  and  kept  up  in  neighboring  parts  by  inflammation  connected  with 
sustained  ichorous  secretion,  the  maKgnancy  of  the  growth  may  be  at 
least  strongly  suspected. 

(e.)  Malignant  new  growths  are  said  to  abound  in  albumen  and  casein ; 
benignant  new  growths,  in  fibrin  and  gluten. 

Were  such  a  distinction  of  new  formations  not  rendered  nugatory  by 
the  convertibility  of  those  organic  substances,  it  would  become  in  a  great 
measure  deprived  of  its  value  by  the  number  and  weight  of  the  excep- 
tions,— for  example,  those  of  fibrinous  tubercle,  of  fibrous  cancer,  the 
composition  of  which  is  marked  by  a  considerable  amount  of  gluten,  &c. 
(/.)  Homoeoplastic  formations  are,  for  the  most  part,  benignant,  hete- 
roplastic  growths  malignant. 

Supposing  such  a  distinction  admitted,  its  utility  would  still  be  doubt- 
ful, seeing  that  in  a  given  case  the  decision  frequently  depends  upon  the 
method  followed  in  the  examination,  and  upon  individual  opinion ;  and 
again,  that  in  many  new  formations,  homoeoplasia  and  heteroplasia 
coexist  in  various  gradations.  For  the  more  marked  repetitions  of  nor- 
mal textures,  namely,  areolar,  cartilaginous,  osseous  new  growths,  the 
character  of  benignancy  might  indeed  be  predicated ;  whilst,  on  the  other 
hand,  certain  forms  of  malignant  fibrous  cancer  bear  so  close  a  resem- 
blance to  the  benignant  fibroid  new  growth  as  to  set  discrimination  at 
nought. 

Microscopic  analysis,  therefore,  from  which  important  disclosures  in 
relation  to  the  diagnosis  of  benignant  and  of  malignant  growths,  and 
tenable  grounds  for  the  establishment  of  a  system  were  expected,  has  in 
reality  thrown  but  an  uncertain  light  upon  the  subject. 

Certain  new  growths  are  especially  intended  for  the  more  or  less  per- 
fect restitution  of  loss  of  substance,  howsoever  occasioned.  These  rege- 
nerated textures  are  sometimes  perfectly  identical  with  the  lost  ones,  in 
formal  and  chemical  composition,  as  also  in  function ;  sometimes  entirely 


ORGANIZED  NEW  GROWTHS.  77 

dissimilar.  The  latter  kind  are  represented  in  scar-texture,  which, 
again,  may  have  an  evanescent  existence,  as  in  provisional  cicatrix^  out 
of  which  is  developed,  and  which  merges  in,  a  texture  identical  with  the 
lost  one ;  as,  for  instance,  the  fibroid  scar-texture  that  ensues  upon  loss 
of  substance  in  the  bones  of  the  skull ;  the  scar-callus  occurring  at  the 
point  of  a  lesion  of  continuity  in  a  nerve.  Or  again,  the  cicatrix  may 
be  permanent,  consisting  throughout  of  a  fibrous  texture  of  various 
degrees  of  perfection,  in  which  the  elements  of  the  lost  texture  are  never 
reproduced ;  such  is  the  muscular,  the  glandular  cicatrix. 

New  growths  once  established  either  sustain  themselves  without  alte- 
ration of  bulk,  or  else  wane  and  shrivel  in  various  ways,  or  even  disap- 
pear altogether.  Products  of  inflammation,  even  such  as  have  assumed 
a  textural  character,  unquestionably  become  reabsorbed ;  so,  in  like 
manner,  do  new  growths  of  embryonic  structure. 

Again,  they  liquefy  under  various  transformations  of  their  chemical 
components,  or  they  become  diseased  in  manifold  ways. 

Finally,  new  growths  increase.  This  increment  takes  place  through 
juxtaposition;  that  is,  through  the  accession  of  blastema  upon  the  peri- 
phery of  the  existing  structure.  Such  is  the  growth  of  non-vascular 
formations,  especially  of  those  which  do  not  rise  above  the  lowest  grade 
of  development ;  as,  for  example,  tubercle.  Or  the  increase  takes  place 
through  the  intussusception  of  new  blastema  from  those  bloodvessels  of 
the  diseased  organ  which  supply  the  new  growth,  or  from  an  adventi- 
tious vascular  apparatus  newly  developed  for  the  supply  of  the  new  for- 
mation. Finally,  an  increase  of  volume  may  be  based  upon  the  variety 
of  chemical  conversions  attending  the  development  of  textural  elements 
out  of  blastema,  and,  in  vascularized  heterologous  products,  attending 
the  growth  of  those  elements  themselves. 

Growth  and  intrinsic  development  by  no  means  keep  pace  with,  but 
rather  stand  in  an  inverse  ratio  to,  each  other.  Rapidly  vegetating 
heterologous  growths  are  mostly  distinguished  by  an  embryonic  structure. 

Upon  the  rapidity  of  its  growth  depends,  in  a  great  measure,  the 
degree  of  influence  exercised  by  the  heterologous  product  upon  the 
affected  organ,  upon  its  vicinity,  and  upon  the  organism  generally. 

This  influence,  considered  locally,  consists  in  pressure  and  tension  of 
textures  and  of  entire  organs ;  in  displacement  and  extinction  of  tex- 
tures ;  consequently,  in  the  production  of  pain,  and  in  embarrassment  or 
complete  hindrance  of  function. 

The  influence  upon  the  entire  organism  is  sometimes  deducible  from 
that  which  is  local,  shaping  itself  differently  according  to  the  different 
seat  of  the  new  formation.  In  the  instance  of  heterologous  products 
luxuriating  by  growth  and  multiplication,  this  influence  consists  in 
causing  the  wasting  of  organic  matter  and  of  power,  or  in  the  establish- 
ment of  a  consecutive  dyscrasial  state.  This  latter  may  be  brought 
about  in  a  twofold  manner : 

(a.)  Either  through  the  withdrawal  from  the  fluid  of  nutrition  of  some 
particular  substance  employed  as  a  material  in  the  heterologous  structure 
— as  in  defibrination  of  the  blood  and  oedema  in  tubercle — in  dropsy  con- 
sequent upon  albuminuria. 

(b.)  Or  else  in  a  positive  manner,  namely,  through  reception  into  the 


78  BLASTEMA. 

blood  and  lymph  of  substances  generated  in  the  interchange  of  matter 
that  constitutes  the  nutritive  process  of  the  heterologous  product,  and 
still  more  through  reception  of  the  heterologous  matter  itself,  in  the 
shape  of  intercellular  substance,  or  of  elementary  cells,  and  the  like. 
This  directly  leads  to  contamination  of  the  fluid  of  nutrition,  and  thereby 
to  a  dyscrasy  reflecting  the  character  of  the  heterologous  growth.  It  is 
the  more  speedily  brought  about  where  circumstances  are  generally  favor- 
able to  endosmosis  or  resorption,  and  particularly  so  in  the  locality  of 
the  heterologous  growth,  where  this  latter  is  bulky  or  highly  vascular, 
or  situate  in  organs  rich  in  blood  and  lymph-vessels,  where  its  mass  (its 
intercellular  substance)  is  more  or  less  fluid.  It  occurs,  however,  in 
heterologous  growths,  both  solid  and  poor  in  bloodvessels,  when  their 
texture  has  become  disintegrated  and  liquefied  by  hypersemia  and  inflam- 
mation. To  sum  up,  new  growths  possess  sometimes  a  general,  some- 
times a  local  character.  Nay,  one  and  the  same  new  formation  may,  at 
various,  successive  periods,  acquire  now  the  one,  now  the  other  character. 
A  growth,  originally  of  general  import,  may  in  particular  assume  a  local 
one  instead. 

New  growths  vary  considerably  as  to  the  organs  and  texture  which 
they  affect  by  preference ;  each  possessing,  in  this  respect,  a  scale  of 
frequency  of  its  own.  Some  organs  are  pre-eminently  subject  to  one 
particular  kind  of  new  formation.  » 

Certain  new  formations  become  developed  and  subsist  unmistakably 
in  concurrence ;  certain  others  never  cohabit,  the  presence  of  the  one 
serving  to  exclude  the  other, — the  appearance  of  the  one  arresting  the 
development  of  the  other.  Exclusiveness  or  repulsiveness  of  this  kind 
is,  as  might  be  expected,  mutually  evinced  by  new  growths  based  upon 
dyscrases  of  opposite  characters.  On  the  other  hand,  new  formations 
rooted  in  kindred  dyscrases,  do  exist  confederately,  and  purely  local 
new  formations  enter  into  every  phase  of  combination. 

Let  us  now  turn  from  the  consideration  of  confirmed  new  formations  to 
that  of  their  blastema  and  of  its  metamorphoses. 

OF  BLASTEMA  AND  ITS  METAMORPHOSES,  WITH   AN   ESPECIAL   REFERENCE 

TO  FIBRINE. 

The  blastema  for  pathological  new  growths  ultimately  proceeds  from 
the  general  fluid  of  nutrition,  the  plasma  of  the  blood.  Accordingly,  its 
source  is  that  out  of  which  all  normal  textures  are  developed.  Its 
bodily  detection  and  demonstration  in  its  simple,  primitive  form,  are, 
however,  mostly  a  matter  of  difficulty,  except,  perhaps,  in  cases  where  it 
is  somewhat  copiously  produced,  in  the  train  of  peculiar  and  often 
rapidly  fatal  processes,  which  may  be  experimentally  analyzed  grade  for 
grade, — for  example,  in  inflammation  and  hypergemia.  It  exudes  through 
the  parietes  of  vessels  wherever  capillaries  exist,  or  it  appears  as  an 
endogenous  segregation  from  the  blood  within  the  circulating  system. 
In  rarer  instances,  it  is  deposited  by  extravasation  out  of  lacerated 
vessels. 

The  blastema  is  originally  fluid,  and  it  may  either  abide  in  this  condi- 
tion or  solidify.  The  earlier  or  later  solidification,  that  is,  its  becoming 


BLASTEMA.  79 

a  fixed  elementary  body,  and  the  degree  of  the  resulting  density  and 
consistence  depend  mainly  upon  the  presence  of  coagulable  protein,  and 
upon  the  degree  of  its  coagulability,  as  also  upon  the  absence  of  those 
counter-checks  to  coagulation,  alkalies,  acids,  and  certain  salts. 

Rapidly  solidifying  blastemata,  especially  when  products  of  inflamma- 
tion, are  very  commonly  termed  plastic, — improperly,  however,  because 
coagulability  of  the  blastema  stands  by  no  means  in  any  direct  relation 
to  the  faculty  of  development.  '  Many  blastemata,  distinguished  for  their 
coagulability,  do  not  rise  above  the  lowest  grade  of  form-development, 
and  not  alone  do  they  stop  at  the  grade  marked  out  by  the  process  of 
coagulation,  but  their  ulterior  tendency  is  to  liquefy.  An  example  is 
afforded  in  tubercle. 

As  a  fluid,  primitive  blastema  recently  secreted  is  amorphous.  Sooner 
or  later,  however,  it  is  marked  by  the  development  of  form-elements,  in 
the  shape  of  molecular  granule,  nucleus,  cell.  Solidified  blastema  is 
either  at  the  outset  amorphous,  or  displays,  from  the  moment  of  coagu- 
lation, certain,  and,  indeed,  higher  elementary  forms, — more  especially 
fibrillation. 

The  blastemata  are  colorless,  or  they  assume  the  tint  of  the  plasma, 
or  they  are  of  a  reddish  gray, — the  fibrinous  of  various  tones  of  yellow, 
— the  albuminous,  whitish,  particularly  when  fat  enters  simultaneously 
into  their  composition, — or  they  display  various  shades  of  red  from 
adhering  blood-pigment,  or  from  the  presence  of  blood-globules,  &c. 

Chemically  considered,  all  blastemata  for  pathological  new  growths 
are  protein  compounds,  for  the  most  part  in  various  degrees  of  oxidation. 

The  main  conversion  which  the  blastema  undergoes  is  its  development 
into  textures.  It  is  capable,  however,  of  abiding  in  its  rude  primitive 
condition — of  remaining  dormant — or  of  breaking  up,  or  lastly,  even  of 
becoming  reabsorbed. 

Before  we  proceed  to  consider  these  several  attributes  of  blastemata, 
it  seems  desirable  for  us  to  render  ourselves  familiar  with  the  main  con- 
ditions for  its  development  or  non-development. 

If,  participating  in  the  current  opinions  as  to  the  conditions  necessary 
for  the  development  of  blastema,  we  admit 

(a.)  A  faculty  of  development  originally  and  essentially  inherent  in 
the  blastema,  and  inseparable  from  the  idea  conveyed  by  the  term. 

(b.)  The  necessity  of  certain  outward  and  general  conditions,  particu- 
larly a  mean  temperature,  the  presence  of  water  (moisture)  and  of  oxygen. 

(<?.)  The  necessity  of  extant  life  in  the  textures  into  which  the  blastema 
is  effused,  and  a  fortiori,  in  the  individual.  In  necrose  textures  no 
development  takes  place  at  all. 

(d.)  The  necessity,  in  order  to  become  developed,  that  the  blastema 
should  abide  in  close  contact  with  the  living  textures;  for  beyond  this 
the  influence  of  the  vital  power  certainly  appears  to  be  limited.  The 
development  of  blastema  usually  commences  close  to  the  living  textures, 
and  bulky  effusions  of  blastema  remain  in  a  backward  state  when  removed 
from  these  textures  lingering  either  in  their  rude  primitive  condition,  or 
at  the  stage  of  form-development,  determined  by  coagulation,  or  lastly, 
breaking  up. 

(e.)  The  specific  influence  exerted  by  circumjacent  textures  upon  the 
mode  of  development,  and  upon  the  form  of  blastema.  We  know  that, 


80  BLASTEMA. 

in  the  act  of  nutrition,  of  regeneration,  even  in  pathological  processes, 
blastema  in  areolar  tissue  becomes  developed  into  areolar  tissue ;  blas- 
tema in  serous  membranes  into  areolar  tissue,  nay,  even  into  serous 
layers  and  sacs  ;  blastema  in  bone,  into  bone  ;  we  know  that,  in  tumors, 
fibroid  textures  often  imitate  the  texture  of  the  organ;  that  fibroid 
tumors  of  the  uterus,  for  example,  represent  the  elementary  forms  of 
organic  muscular  fibre ; — that  in  bones,  cartilaginous  new  growths  are 
wont  to  assume  the  form  of  enchondroma. 

All  this  generally  admitted,  the  failure  of  such  influence  does  not,  as 
regards  many,  and  the  more  momentous  cases,  appear  satisfactorily  to 
explain  either  the  non-development  of  blastema,  its  tarrying  in  its  rude 
primitive  condition,  its  arrest  at  an  inferior  stage  of  embryonic  develop- 
ment, its  disintegration,  or  its  development  to  unwonted  heterogeneous 
textures.  This  becomes  the  more  obvious  if,  in  relation  to  the  aforesaid 
conditions,  we  reflect : 

(a.)  That,  as  a  rule,  the  absence  of  moisture  is  not  absolute,  and  that 
it  is  also  in  other  ways  conditional. 

(b.)  That  the  absence  of  an  adequate,  general,  and  specific  influence 
in  the  circumjacent  textures  can  never  be  assumed  directly,  but  only 
through  the  one-sided  conclusion  that,  notwithstanding  the  existence  of 
other  requirements,  a  blastema  has  failed  to  become  developed,  a  fact 
which  might  admit  of  a  very  different  interpretation. 

Thus,  to  discuss  a  matter  of  the  greatest  importance  in  the  arena  of 
facts,  the  sojourn  of  certain  fixed  blastemata, — for  example,  tubercle — 
in  the  primitive  condition,  is  not  ultimately  referable  to  the  absence  of 
moisture ;  the  absence  or  rather  paucity  of  water  depending  upon  the 
high  degree  of  coagulability  proper  to  the  said  blastema.  This  coa- 
gulability must,  however,  be  inherent  in  the  blastema  itself.  Again, 
there  are  blastemata  which  never  get  beyond  the  embryonic  grades  of 
development, — for  example,  the  pus-blastema,  the  blastema  of  medul- 
lary and  of  colloid  cancer.  Deficiency  of  vital  power,  or  of  determining 
influence  on  the  part  of  surrounding  textures  cannot,  in  every  instance, 
furnish  grounds  for  the  non-development  of  blastema.  Thus  we  see  very 
minute  portions  of  blastema, — for  instance,  of  tubercle — in  robust  indi- 
viduals, in  the  closest  contact,  with,  nay,  in  the  centre,  of  vigorous  tex- 
tures, undeveloped.  On  the  other  side,  in  a  very  low  degree  of  vital 
power,  where  one  might  rather  expect  little  or  no  blastema  to  be  pro- 
duced, we  meet  with  enormous  masses  of  it  under  various  forms  of  hete- 
rologous  growths,  engaged  in  the  process  of  development.  The  pheno- 
menon so  commonly  regarded  as  an  arrest  of  textural  development, — 
founded  in  deficiency  of  vital  energy,  of  adequate  working  power, — 
namely,  fibrous  callus,  in  the  regeneration  of  bone, — cicatrix  in  muscle, 
&c., — is,  we  think,  interpretable  as  qualitative  alienation,  the  blastemata 
not  abiding  at  the  embryonic  stages  of  development  of  the  textures  to 
be  regenerated,  but  forming  into  other  textures,  perfect  after  their  kind. 

Still  less  is  this  deficiency  calculated  to  illustrate  that  qualitative 
variety  in  the  development  of  blastemata,  exemplified  in  so  many  hetero- 
logous  growths.  How  should  we  therefrom  apprehend  the  derivation  of 
a  cyst,  of  an  areolar-carcinoma,  and  the  like  ?  How  often  should  we  not 
be  driven,  instead  of  deficiency,  to  assume  an  equally  unintelligible 


BLASTEMA.  81 

excess  of  power,  where  we  find,  in  textures  of  an  inferior  grade,  new 
growths  developed,  the  elements  of  which  belong  to  textures  of  a  higher 
order. 

These  remarks  of  themselves  lead  to  the  conclusion : 

1.  That  the  abnormal  development  of  the  blastemata  is  founded,  not 
in  a  deficiency,  but  in  an  anomaly,  of  determining  influence. 

2.  That  the  different  blastemata  themselves,  at  the  outset,  possess  in- 
dwelling properties  of  their  own.      We  can  have  little  hesitation  in 
establishing,  as  a  basis  of  the  doctrine  of  new  formations,  a  native 
anomaly  in  the  blastemata,  this  being  practically  demonstrable.     Such, 
for  example,  are  the  various  morbid  relations  of  protein  substances,  and 
in  particular  the  anatomically  demonstrable  anomalies  in  the  constitu- 
tion of  fibrin  in  the  blood  itself,  with  which  anomalies  the  different  exu- 
dation, (as  blastemata)  correspond  both  as  to  form  and  chemical  compo- 
sition. 

In  this  manner  certain  blastemata  bear,  in  their  primitive  character 
and  composition,  the  grounds  for  their  non-development, — the  seeds  of 
their  dissolution, — for  example,  croupous  fibrin, — tubercle, — pus-blas- 
tema. 

Other  blastemata,  on  the  contrary,  possess  the  indwelling  faculty  of 
development  in  so  exalted  and  inextinguishable  a  degree,  as  to  form,  in 
large  serous  cavities,  into  free  aggregations  of  blastema  without  any 
abiding  contact  with  textures — free  fibroid  concretions. 

Areolar  new  growths  are  so  frequent,  simply,  in  our  opinion,  because 
their  blastemata  are  so  frequent,  and  their  production  consequent  upon 
so  many  different  processes  of  exudation. 

The  blastema  for  animal  muscular  fibre  appears,  on  the  contrary,  to 
exude  only  in  the  normal  process  of  nutrition,  or  where  this  process  is 
exaggerated  to  hypertrophy. 

It  is  very  common  for  mixed  blastemata  to  exude.  Hence  the  fre- 
quent coincidence,  in  one  and  the  same  new  formation,  of  such  various 
elementary  forms,  and  of  such  different  modes  of  development. 

Primitive  anomalies  of  blastema  may  be  occasioned  in  a  twofold 
manner : 

(a.)  They  may  be  rooted  in  a  general  dyscrasy  of  the  sanguineous 
mass.  The  effusion  of  blastema  coincides  with  manifest  anomaly  of 
general  nutrition.  The  blastema  bears  the  impress  of  dyscrasial  adul- 
teration. This  is  particularly  the  case  with  blastemata  deposited  in 
mass  as  inflammatory  products.  Indeed,  the  copious  production  of 
blastema  in  reduced,  enfeebled  subjects,  admits  of  no  other  conclusion 
than  that  of  a  dyscrasial  condition  as  the  source  of  such  effusion ;  the 
specific  character  of  the  latter  being  simultaneously  manifested  by  its 
obvious  preference  for  particular  organs. 

(5.)  Again,  the  said  primitive  anomalies  may,  where  the  general  crasis 
is  untainted,  be  based  in  an  altered  admixture  of  the  plasma  (the  blood) 
owing  to  local  changes  of  innervation ;  or  else  in  an  anomalous  act  of 
nutrition,  for  example,  inflammation. 

In  the  former  case,  the  blastema  is  a  symptomatic  manifestation  of  a 
constitutional  disease,  and  is  of  general — in  the  latter  case  it  is  of  mere 

VOL.  I.  6 


82  COAGULATED    FIBRIN. 

local — import.  The  same  blastema,  pus,  cancer-blastema,  for  instance, 
may,  in  one  case,  imply  general,  in  another,  local  disease. 

A  new  growth  would,  however,  be  equally  of  local  significance  if  it 
resulted  from  a  blastema  of  originally  normal  character  through  an 
anomalous  determining  influence  on  the  part  of  the  nerves  or  textures, 
or  of  an  anomalous  interchange  of  matter  (resorption,  &c.) 

Amongst  the  many  causal  relations,  the  mode  of  operation  of  which 
is  unknown,  mechanical  influences  are  by  no  means  the  least  frequent 
originators  of  anomalous  blastemata  through  local  changes  of  innerva- 
tion  and  of  textural  influence. 

We  shall  now  leave  this  discussion,  and  proceed  to  an  inquiry  con- 
cerning the  metamorphoses  of  blastema.  Amongst  these,  the  first  rank 
is  taken  up  with  the  development  of  blastema  into  textures.  Here  solid 
blastemata,  as  the  groundwork  of  pathological  new  growths,  present  so 
great  a  difference  from  fluid,  that  the  two  must,  as  far  as  possible,  be 
separately  considered. 

The  latter  are  all  developed  according  to  the  laws  of  the  cell  theory, 
whilst  the  former  disclose,  besides  a  variety  of  granule  and  of  fibro- 
nucleus  formations,  a  direct,  and,  for  the  most  part,  preter-physiological 
development,  in  various  ways,  to  higher  elements  in  the  shape  of  fibre. 

Blastemata  of  this  description  are  represented  by  coagulated  fibrin 
and  coagulated  albumen.  In  the  identity,  however,  of  the  process  of 
development  in  both,  fibrin  is  pre-eminently  adapted  for  experimental 
study,  owing  to  the  greater  frequency  of  its  occurrence,  especially  in  an 
aggregate  and  bulky  form.  Under  certain  conditions,  its  coagulation 
alone  suffices  to  constitute  textural  formation.  We  shall,  therefore,  do 
well  to  preface  an  inquiry  into  the  nature  of  solid  blastemata  by  the 
study  of  coagulate  fibrin  in  its  relation  to  the  doctrine  of  exudation  and 
of  blood  disease. 

COAGULATED  FIBRIN. 

The  simple  coagulum  met  with  in  the  heart  or  great  vessels  after 
death,  and  in  blood  drawn  from  bloodvessels  during  life,  furnishes  the 
chief  groundwork  for  this  inquiry. 

These  coagulations,  which  vary  essentially,  both  as  to  external  ap- 
pearance and  to  elementary  constitution,  form  the  basis  of  the  different 
qualitative  fibrin  erases.  We  should,  however,  begin  by  stating  that  the 
individual  forms  seldom,  if  ever,  occur  in  their  perfect  simplicity,  owing 
both  to  the  mutable  nature  of  the  substance,  and  to  the  fibrin  not  be- 
coming throughout  equally  influenced  by  the  disease.  This  corresponds 
to  the  numerous  exudates  composed  of  differently  constituted  fibrinous 
materials,  as  also  to  the  frequent  impurity  of  blastemata  in  general. 

The  more  important  forms,  described  from  the  most  perfect  specimens, 
are  as  follows : — 

1.  Fibrin  taken  from  the  dead  bodies  of  healthy  individuals,  presents 
tolerably  compact  and  tough,  moderately  adhesive  coagulations  of  a 
yellowish  white.  These  are  separable  into  membranous  layers,  and  their 
torn  surface  exhibits  a  delicately  villous  character.  Viewed  under  the 
microscope,  they  display  a  transparent  basement,  capable  of  membra- 
nous expansion,  or  else  stratified.  Upon  this  is  a  dense  felt,  freely 


COAGULATED    FIBRIN.  83 

erect  at  the  edges  of  the  preparation,  and  consisting  of  very  minute, 
very  elastic,  ramified  fibres,  visible  in  black  outline,  and  rapidly  soluble 
in  acetic  acid.  Hard  by  on  the  preparation,  are  seen  numerous  round 
polished  nuclei,  which,  when  treated  with  acetic  acid,  are  brought  more 
distinctly  into  relief.  Beside  these  lie  scattered  minutely  granular,  dull, 
round,  and  elliptic  nuclei,  and  similar  cells,  the  size  of  pus-cells,  color- 
less blood-globules,  lymph-globules  (fibrin-globules,  according  to  Mandel\ 
the  same  form-elements  which,  in  exudates,  are  termed  plastic  cor- 
puscles (Bennett)  exudation  cells  (Henle).  (See  also  Pappenheim, 
Addison,  and  others.) 

The  soft,  jelly-like  coagula  of  so-called  spurious  fibrin,  found  to 
accompany  the  above-mentioned  compact  coagula,  and  in  certain  cases 
to  constitute  the  whole  of  the  impoverished  fund  of  fibrin,  show  the  same 
composition.  They  constitute,  we  think,  a  transition  form  from  albumen 
to  fibrin,  of  great  moment  in  relation  to  the  normal  process  of  nutrition. 

2.  Fibrin  the  coagula  of  which,  though  of  the  ordinary  appearance, 
possess  the  property  of  adhesiveness  in  a  more  marked  degree,  and  fre- 
quently inclose  not  inconsiderable  quantities  of  serum.     Examined  with 
the  microscope,  they  present  a  laminated  basement,   and  one  splitting 
into  fibres,  flattened  or  roundish,  rough,  and  firm,  or  resembling  organic 
muscular  fibres ;  or  else  a  membranous  basement  invested  with  delicate 
wavy  fibres,  upon  which,  amongst  elementary  granules,  are  seen  nume- 
rous round,  black-edged  nuclei,  sometimes  rod-shaped,  or  drawn  out  into 
fibres,  and  again,  more  especially  in  the  moisture  poured  out,  dull,  round, 
and  oval  nuclei,  and  analogous   cells.     This  fibrin  enters — along  with 
rudiments  of  the  preceding  one — into  frequent  combinations  with  those 
about  to  follow. 

This  and  the  preceding  fibroid  together  furnish  the  basis  of  numerous 
areolar  or  fibrinous  new  growths,  whether  simple  or  combined  with  other 
blastemata,  both  within  and  without  the  vascular  system ;  textural  de- 
velopment having  set  in  with  the  process  of  coagulation  itself.  The 
exudation  of  the  last  specified  form  of  fibrin  is  especially  wont  to  ac- 
company morbid  processes ;  for  example,  inflammation,  and  frequently 
in  considerable  abundance.  It  might  be  designated,  for  distinction's 
sake,  as  plastic  or  organizable  fibrin. 

3.  Fibrin,  the  coagula  of  which  are  marked  by  opacity,  and  by  a  dull- 
white   aspect  shaded  with  yellowish,   or  with   yellowish-green.     They 
frequently  include,  besides  blood-serum,  blood-corpuscles  in  considerable 
amount,  thus  giving  proof  both  of  augmented  coagulability,  and  greater 
rapidity  of  coagulation.     They  are  opaque,  and  of  various  shades  of  red. 
Microscopically  examined,  the  coagulum  presents  a  stratiform  or  fibro- 
laminated  basement,  or  else  a  faintly  striated  membrane,  both  being, 
however,  opaque,  owing  to  delicate  granulation  (Punktmasse).     Upon 
this,  as  also  in  the  serum,  are  seen  a  vast  number  of  nucleus-like  forma- 
tions, of  developed,  dull  granulated  nuclei,  and  of  similar  more  or  less 
developed  cells.     Frequently  the  coagulum  appears  to  consist  altogether 
of  the  two  last-mentioned  elements,  with  a  proportion  of  granulated 
structure.     The  nucleus-formations  all  manifest  the  usual  neutral  rela- 
tions towards  acetic  acid.      This  fibrin  possesses  little   adhesive  pro- 
perty. 


84  COAGULATED    FIBRIN. 

4.  Fibrin  presenting  in  a  higher  degree  the  morbid  characters  mani- 
fested in  the  preceding  variety.  The  coagula  are  extremely  opaque,  and, 
where  they  inclose  no  blood-corpuscles,  of  a  more  marked  greenish- 
yellow  tinge.  Frequently,  however,  they  do  inclose  vast  quantities  of 
blood-corpuscles,  and  are  of  a  reddish-gray  or  a  reddish-brown,  denoting 
rapid  coagulation.  Upon  a  closer  examination,  they  are  found  to  consist 
of  a  compact,  delicately  granulated  mass  of  nucleus  and  cell-formations 
(assimilating  in  various  degrees  to  the  pus-cell  and  pus-nucleus),  all  held 
together  by  a  tough  amorphous  intercellular  substance.  There  is  neither 
fibrous  tissue  nor  any  fibrillation.  These  coagula  possess  still  less  of  a 
cementing  property. 

These  two  latter  forms  we  would  designate  as  croupous  fibrin.  Here 
the  fibrin  borders  upon  that  in  pyaemia,  and  has  the  croupous  character. 
The  cells  and  nuclei  included  in  the  coagulum  are  genuine  pus-nuclei  and 
pus-cells.  Other  morbid  conditions  of  fibrin — for  example,  the  milky 
white  opaque  fibrin — are  of  little  moment  as  regards  the  present  subject. 
They  will  be  considered  under  the  head  of  Crases. 

These  forms  of  fibrin  possess,  from  the  very  first,  an  indwelling  prone- 
ness  to  textural  formation,  and  a  disposition  to  molecular  disintegration 
— nay,  they  have  already  entered  upon  both  the  one  and  the  other 
transformation.  The  fibrin  1  and  2,  are  organizable ;  the  fibrin  3  and 
4  suffer  disintegration ;  portions  of  thte  fibrin  1  and  2  that  mingle  with 
it  being  alone  susceptible  of  textural  transformation,  as  is  so  frequently 
witnessed,  extraneously  to  the  vascular  system,  in  exudations  of  a  kin- 
dred stamp.  Fibrin  4  presents  no  definite  coagulum  at  all. 

These  forms  of  fibrin  correspond  in  some  measure  with  Mulder's  gra- 
dations of  the  oxidation  of  protein.  Here,  however,  chemical  analysis 
has  assuredly  not  kept  pace  with  anatomical  facts. 

Coagula  assuming  as  it  were  the  form  of  intercellular  substance,  are 
liable  to  both  kinds  of  metamorphosis.  The  differently  apportioned 
nucleus  and  cell-formations  here  play  a  subordinate  part,  their  import- 
ance varying,  as  has  been  stated,  from  the  nucleus  employed  in  the 
fabric  of  textures,  to  the  true  pus-nucleus  and  pus-cell.  Hence  they 
are  the  manifestation  either  of  a  quantitative  endogenous  development 
of  textural  rudiments,  or  else  of  a  qualitative  affection  of  the  plasma. 

1.  The  structural  transformation  comprised  in  the  process  of  coagula- 
tion, consists  in  the  afore-mentioned  diverse  fibre-and  membrane-forma- 
tion.    The  nuclei  themselves,  sometimes  appear  elongated  into  rod-  or 
perhaps  spindle-shaped  fibre-stems.     In  the  cells  the  caudate  form  of 
development  is  seldom  observable. 

2.  The  second  metamorphosis  is  disintegration.     It  is  foreshadowed 
in  the  granular  mass  that  enters  into  the  coagulation.     After  probably 
a  brief  interval,  the  entire  coagulum  resolves  itself  into  a  pulpy,  cream- 
like,  whitish,  or  yellowish-white,  or,  if  containing  blood-corpuscles,  into  a 
proportionally  faint  reddish-gray,  reddish-brown,  or  chocolate-colored 
liquor,  pregnant  with  granulated  substance  along  with  the  nucleus  and 
cell-formations  originally  admitted  into  the  coagulation,  and  becoming, 
where  the  latter  are  numerous,  relatively  analogous  to,  and  where  they 
assume  the  character  of  pus-nuclei  and  pus-cells,  identical  with,  pus. 
This  breaking  down  may,  under  certain  external  conditions,  unfavorable 


COAGULATED    FIBRIN.  85 

to  textural  formation,  or  owing  to  some  indwelling  peculiarity,  affect 
fibrin  generally.  In  croupous  fibrin  it  is  of  unfailing  occurrence.  The 
results  of  Gulliver's  experiments  concerning  the  liquefaction  of  fibrinous 
coagula,  under  the  sustained  influence  of  the  animal  degree  of  heat,  out 
of  the  animal  body,  are  not  applicable  to  the  process  as  occurring 
within  the  living  body,  where  certain  kinds  of  fibrin  of  necessity  become 
converted  into  textures,  whilst  others  as  invariably  liquefy. 

This  process  is  witnessed  with  especial  frequency  in  the  coagula  occur- 
ring within  the  heart,  and  which  Laennec  designated  as  "vegetations 
globuleuses,"  as  also  in  the  coagula  occurring  within  bloodvessels,  both 
great  and  small. 

Liquefied  fibrin  is  capable  of  undergoing  inspissation  and  cretaceous 
conversion. 

Other  transformations  of  fibrin  are : 

3.  The  abiding  of  the  organizable  fibrin  at  the  primitive  stage  of 
formation,  and  its  eventual  extinction.     Here  the  coagulum  is,  with  loss 
of  its  moisture,  reduced  to  a  compact,  unyielding,  semi-translucent,  or 
opaque  and  horny  substance.     It  is  capable  of  eventually  ossifying. 

4.  Fatty  conversion,  in  the  shape  of  a  reduction  to  fat-molecules  of 
various   circumference,  a  metamorphosis  which  coagulate  fibrin  shares 
with  liquid  and  coagulate  albumen. 

5.  Within  the  vascular  apparatus  solidified  albumen,  of  whatever  form, 
may  again  become  incorporated  with  the  circulating  fluid.     Where  this 
liquefaction  of  the  coagulum  is  not  the  consequence  of  inherent  disposi- 
tion, it  is  wrought  by  gradual  solution  in  the  plasma,  becoming,  so  to 
say,  corroded,  layer  for  layer,  by  the  liquor  sanguinis.     Examples  offer 
in  the  progressive  resolution  of  solidified  vegetations  upon  the  heart's 
valves,  or  of  the  thrombus  in  arteries.     It  corresponds  to  the  resorption 
of  the  consolidated  fibrin  of  exudation  and  of  extravasation. 

We  have  hitherto  expressly  restricted  ourselves  to  an  inquiry  con- 
cerning the  consolidation  and  the  metamorphoses  of  fibrin  within  the 
vascular  apparatus,  as  exemplified  in  the  diverse  spontaneous  coagula- 
tions which  occur  in  the  heart,  not  rarely  during  life ;  and  again  in  coagu- 
lations within  the  larger  vessels  (more  especially  the  veins),  and  also  in 
the  capillaries. 

The  relations  of  the  fibrin  of  exudation  are  precisely  the  same. 

The  organizable  nature  of  the  fibrin  of  exudation  might  be  confidently 
assumed  a  priori ;  it  is,  however,  as  shown  under  the  head  of  hemor- 
rhage, directly  demonstrable  by  facts. 

Contrasting  the  frequency  with  which  solid  blastemata  constitute  the 
basis  of  pathological  new  growths,  with  their  rareness  in  the  physiologi- 
cal condition ;  reflecting,  at  the  same  time,  upon  the  predominance  of 
cell-development  in  physiological  structures  ;  and  lastly,  upon  the  absence 
of  fibrin  in  the  embryo,  we  feel  somewhat  disposed  to  concur  with  Zim- 
mermann,  in  regarding  fibrin  as  a  genuine  excretive  formation ;  a  sub- 
stance carried  by  oxidation  to  the  verge  of  disintegration, — albumen 
worn  out  by  oxidation,  and  associated  with  albumen  for  the  purposes  of 
nutrition,  only  in  the  shape  of  pseudo-fibrin. 


METAMORPHOSIS    OF    BLASTEMA. 


METAMORPHOSIS   OF   BLASTEMA. 

1.  Textural  development. — Organization. 

Solidified  Blastemata,  at  their  very  development,  either  constitute 
various  pure  and  unmingled  new  growths,  or  enter  in  the  shape  of  inter- 
cellular substance,  basement-  and  bond-mass,  as  the  stroma  into  the  com- 
position of  complex  heterologous  structures.  Their  development  is,  for 
the  most  part,  foreshadowed  in  the  types  cast  in  the  process  of  coagula- 
tion, and  which  were  partly  discussed  in  the  foregoing  chapter. 

The  principal  abiding  form-element  that  enters  into  the  composition 
of  new  growths  is  the  anastomosing,  delicate  fibrous  network  of  consoli- 
dated fibrin.  This,  together  with  a  hyaline  intercellular  substance, 
speckled  throughout  with  shining  nuclei,  we  have  seen  in  old  inflamma- 
tory indurations  in  the  brain,  as  also  composing  an  extensive  fibrous 
cancer  in  the  stomach. 

Solid  blastema  either  appears  originally  as  a  compact  mass,  or  else 
takes  up  a  considerable  amount  of  moisture,  and  establishes  a  sort  of 
skeleton-work  with  variously  shaped  gaps,  offering  a  specific  type  of  much 
interest.  From  a  central  mass,  namely,  arises  a  trelliswork,  the  rods  of 
which  are  sometimes  isolated,  sometimes  anastomose  with  each  other, 
constituting  a  network  with  largish,  and  for  the  most  part,  oval  meshes. 
This  type  characterizes  in  particular  the  opaque  accumulations  found 
upon  the  internal  coat  of  arteries,  as  also  certain  fibrous  tumors,  espe- 
cially when  seated  upon  the  dura  mater.  Or,  again,  solid  blastema  as- 
sumes the  form  of  a  membrane,  either  superficially  spread  out,  or  folded 
and  rolled  up  in  a  tubular  form, — a  cylindrical  fibre. 

The  blastema  is  here  amorphous,  laminated ;  or  it  presents  upon  lace- 
ration, a  striated,  fibrous  aspect.  It  may  assume,  owing  to  the  presence 
of  elementary  molecules,  various  degrees  of  opacity,  or  a  granulated  look ; 
or  it  may  display  crystalline  clearness.  Lastly,  it  may  or  may  not  in- 
clude nuclei  and  cells,  in  various  proportions. 

Solid  blastema  of  each  of  the  specified  forms  is  worked  out  into  fibres 
by  splitting : 

1.  Either  directly  into  areolar  fibre  and  fibril,  or  else 

2.  Into  flat,  riband-like,   rough-surfaced,  jagged,   or  into  roundish, 
oval,  mostly  felt-like  fibres,  of  from  TJo  to  g^th  of  a  millimetre  in  their 
broad  diameter. 

3.  Into  fibres  perfectly  identical  with  those  of  the  organic  muscles. 
By  renewed  splitting,  for  the  most  part  commencing  at  their  ends,  the 

two  latter  kinds  may  give  rise  indirectly  to  areolar  fibrillation. 

Where  there  are  nuclei  present,  engaged  in  the  development  into 
oblong  nuclei,  the  splitting  takes  place  in  the  direction  of  their  longitu- 
dinal axis. 

The  aforesaid  cylindrical  fibres  represent  little  tubular  bodies  of  from 
TJoth  to  j0th  of  a  millimetre  in  diameter,  which  end  either  in  bulb-like 
dilatations,  or  in  sharp  points,  frequently  inosculate,  and  constitute  a  wide- 
meshed  villous  network.  Their  parietes  are  formed  by  a  transparent, 
structureless,  often  wavy  membrane,  in  a  single  or  double  fold.  Their 
contents  are  elementary  granules, — in  hemorrhagic  blastema,  pigment- 
granules  additionally, — nucleus  formations,  cells,  together  with  an  ampho- 


METAMORPHOSIS    OF    BLASTEMA.  87 

rous  blastema  in  varying  quantity.  Cylindrical  fibre  at  its  parietes  be- 
comes areolar  fibril,  or  perhaps  this  fibrillation  is  first  developed  in  the 
blastema  within  the  canal,  as  a  delicately  fibrous  wave-curled  axis- 
cylinder.  Such  fibres  are  commonly  coincident  with  the  primitive  forms 
of  blastema,  more  especially  with  the  trelliswork  described.  We  have 
frequently  examined  them,  and  we  regard  them  as  analogous  with  the 
cylindrical  formations  occurring  in  fluid  blastemata  (Engels  germ-tubes.) 
Other  kinds  of  fibre  arise  directly  out  of  splitting,  but  more  slowly,  it 
would  appear,  and  only  after  the  blastema  has  entered  upon  essential 
chemical  changes  (as  partial,  glutinous,  or  horny  conversion).  They  are 
characterized  by  their  neutral  relation  to  acetic  acid,  or  at  least  by  their 
stubborn  resistance  to  its  influence.  Through  progressive  transitions  they 
ultimately  attain  to  uniformity  with  elastic  and  nucleus-fibre  with  which 
they  further  accord  in  blackness  of  outline,  in  solidity,  and  in  elasticity. 
Of  this  nature  are 

1.  A  transparent  fibrillation  for  the  most  part  solid,  the  fibre  varying 
in  diameter  from  that  of  the  areolar  fibril  to  one  of  undefinable  minute- 
ness. 

2.  A  fibrillation  in  black  outline,  vibrating  in  lengthy  deviations. 

3.  A  twig -like  fibrillation  arising  out  of  a  short  stem,  with  black  con- 
tours. 

4.  A  fibre-felt,  resembling  the  intercellular  substance  of  reticulated 
cartilage. 

The  appearance  in  the  blastema  of  roundish  gaps,  created  by  resorp- 
tion,  is  likewise  deserving  of  notice.  In  this  manner  solid  masses  of 
blastema  acquire  a  porous,  honeycombed  aspect,  whilst  membranous  blas- 
temata become  pierced  or  loopholed  tunics.  This  does  not,  however, 
prevent  the  blastema  either  from  remaining  amorphous  or  from  under- 
going fibrillation.  Amongst  the  elementary  granules,  nuclei,  and  cells 
which  occur  in  various  number  in  solid  blastema,  it  is  more  especially 
the  two  former,  and  most  frequently  the  nuclei,,  that  undergo  further 
elaboration. 

1.  Even  in  recent  fibrinous  coagula,  within  the  vascular  system,  rod- 
like  nucleus  formations  are  discoverable.     They  enter  into  the  composi- 
tion of  many  delicately  fibred  textures. 

2.  The  nucleus  is  developed  through  the  oblong  form  to  the  caudated 
nucleus,  and  from  thence  directly  into  nucleus-fibre.     Upon  basement 
membranes,  we  often  meet  with  serpentine,  creeper-like  nucleus-fibre 
stems.     The  caudated  nuclei  often  constitute,  when  held  together  by 
an  amphorous  intercellular  mass, — in  rarer  instances  independently, — 
the  fibrous  element  of  not  a  few  heterologous  growths.    More  frequently, 
however,  they  enter  singly  into  the  composition  of  fibrous  textures  of 
other  kinds. 

3.  Contiguous  nuclei,  in  progess  of  fibrous  development,  conjoin  and 
merge  in  the  varicose  nucleus-fibre,  which  by  degrees  acquires  uniformity, 
and  in  rare  instances  forms  the  main  component  of  fibrous  new  growths. 

4.  The  nuclei  form  the  basis  of  the  true  elastic  splitting  fibre. 
Elementary  granules  forming  in  collateral  array,  become  confluent, 

and  establish  in  various  directions,  more  or  less  delicate,  dark-looking, 
longitudinal,  or  reticulated  fibres,  which  resist  the  influence  of  acetic 
acid.  They  are  most  conspicuous  upon  basement  membranes. 


88  METAMORPHOSIS    OF    BLASTEMA. 

In  solid  blastemata  the  elaboration  of  cells  into  fibre  occurs,  for  the 
most  part,  slowly  and  in  the  ordinary  routine.  The  majority  of  the  cells, 
however,  remain  undeveloped,  and  become  reabsorbed.  Still  the  deve- 
lopment of  primary  cells  into  parent-cells,  however  rare,  does  occasionally 
happen. 

Fluid  blastemata,  in  their  development  to  textures,  obey  the  laws  of 
the  cell  theory  (Schwann's).  The  perfect  nucleated  cell,  however,  origi- 
nates in  two  different  ways  : 

(a.)  The  union  of  several  elementary  granules  gives  rise  to  the  nucleus, 
and  around  this  to  the  cell,  with  the  nucleus  impinging  upon  the  wall, — 
the  ordinary  mode.  Or  else — 

(5.)  The  cell  originates  first, — its  primitive  limpid  contents  giving  rise 
to  an  endogenous  nucleo-genesis — for  example,  in  the  blood, — in  exuda- 
tion— in  colloid  and  medullary  cancer. 

Generally  speaking,  the  nuclei  equal  in  size  those  proper  to  physiolo- 
gical textures.  Larger  nuclei,  however,  and  in  particular  oblong,  free 
nuclei  yJoth  to  5*0  th  of  a  millimetre  in  length,  occur  likewise, — in  me- 
dullary cancer,  for  instance.  Inclosed  within  cells,  their  further  develop- 
ment, so  far  as  we  know,  commences  only  after  the  conversion  of  the  cell 
into  fibre.  They  are  round,  oblong,  lustrous,  black-edged,  or  dull  and 
granulated. 

The  cells  present  every  variety  of*  size,  from  that  of  the  exudation- 
and  the  pus-cell  to  that  of  the  largest  ganglion- cell,  and  upwards.  They 
are  in  shape  spherical,  oval,  lengthened  by  branch-like  processes,  rhom- 
boidal,  polyedrical. 

They  mostly  contain  one,  often  two,  occasionally  several  (three,  four, 
or  five),  nuclei. 

The  propagation  of  nuclei  and  cells  occurs  either  immediately  out  of 
the  fluid  intercellular  substance,  as  blastema,  or  within  a  parent-cell. 
Endogenous  nuclei  and  cells  [brood-nuclei  and  cells ;  filial  cells  ;  intra- 
utricular  cell-formation]  from  within  a  primary  cell,  and  distend  it  into 
a  structureless  vesicle,  by  the  eventual  bursting  of  which  they  become 
released. 

In  rarer  instances,  we  meet  with  secondary  cell-formation  around  a 
primary  cell, — an  incasing  of  the  primary  cell. 

The  primary  cell  is  either  permanent  or  adapted  for  ulterior  develop- 
ment, namely — 

1.  The  ordinary  development  of  the  cell  into  fibre.     This  is  brought 
about  by  the  spontaneous  elongation  of  a  cell  to  a  wedge-  or  spindle- 
shaped,  or  a  caudated  cell ;  or  by  the  fusion  of  several  cells,  arrayed  in 
rows  or  columns,  and  engaged  in  the  act  of  elongation  to  a  varicose  fibre, 
the  protuberances  of  which  are  eventually  reduced.     Fibre  produced  in 
either  way  may,  by  splitting  lengthwise,  subsequently  break  up  into 
fibrils.     In  form,  the  fibre  corresponds  with  that  of  areolar  tissue,  or  of 
organic  muscle.     The  cell-nuclei  immediately  form  into  nucleus-fibre, 
into  elastic  fibre.     In  this  wise  do  fluid  blastemata,  under  the  progressive 
consumption  of  the  intercellular   substance,  give  rise  to   fibrous  new 
growths. 

2.  The  above  transformation  differs  from  the  working  out  of  the  pri- 
mary cell  into  the  parent-cell,  and  to  the  production  of  pouch-Uke  forma- 
tions with  endogenous  nucleus  and  cell-development. 


METAMORPHOSIS    OF    BLASTEMA.  89 

(a.)  The  parent-cell  is  a  cyst-like  dilatation  of  the  primary  cell,  and 
its  contents  furnish  the  blastema  for  the  creation  of  filial  cells,  in 
either  of  the  two  modes  before  described.  When  the  latter  have  greatly 
increased  in  number,  the  parent-cell  frequently,  but  not  invariably,  bursts, 
and  is  destroyed.  Not  rarely,  however,  it  becomes  the  groundwork  for 
very  remarkable  textures.  (See  "  Cyst.") 

(a.)  The  structureless  parietes  of  the  growing  parent-cell  acquire  a 
fibrous  texture,  and  thus  become  fundamental  to  the  type  of  the  alveolar 
texture,  and  to  cyst  formation.  (See  "  Cyst.") 

(P.)  The  parent-cell  is  singly,  or  it  may  be  in  fusion  with  others,  de- 
veloped into  a  gibbous,  lobulated,  hollow  body,  resembling  a  glandular 
acinus. 

The  filial-cells  enter  occasionally,  even  within  the  parent-cell,  into  a 
fibrous  development.  Upon  the  dura  mater,  tumors  are  often  met  with 
seemingly  of  glandular  texture.  These  consist  of  conglomerations  of 
caudated  cells,  imbedded  in  a  layer  composed  of  the  same  elements. 
They  are  the  products  of  a  single  parent-cell. 

(b.)  In  fluid  blastemata,  utricular  or  pouch-like  formations  occur, 
similar  to  the  tubular  fibres  mentioned  under  the  head  of  solid  blaste- 
mata, and  they  inclose  nuclei  and  cells  in  various  number.  Their  walls 
appear  structureless ;  although,  on  a  closer  inspection,  one  or  two  nuclei, 
— occasionally  several  movable  nuclei, — may  be  detected  upon  them. 
They  occur  in  colloid,  in  scirrhus,  and  in  sarcoma,  with  a  fluid  inter- 
cellular substance.  Their  functional  import  is,  in  our  opinion,  identical 
with  that  of  the  parent-cell  with  its  brood-elements.  They  present  the. 
greatest  analogy  with  the  capillary  vessel  and  its  contents,  the  more  so 
that  they  probably  originate  through  the  fusion  of  nucleated  or  non- 
nucleated  cells,  arrayed  in  columnar  juxtaposition.  Their  diameter 
ranges  from  the  T^otn  to  tne  tu^h  of  a  millimetre,  and  upwards. 

We  have  now  examined  the  essential  elementary  forms  arising  out  of 
both  solid  and  fluid  blastemata.  Their  secondary  arrangement  into  a 
texture  offers  equal  diversity.  Nuclei,  cells,  nay,  elementary  granules, 
display  infinite  variety  in  their  arrangement,  as  do,  in  like  manner, 
caudated  nuclei  and  cells,  and  the  different  descriptions  of  fibres,  in  their 
course  and  in  their  co-ordination  with  other  concurrent  elements.  These 
relations  wrill  have  to  be  pointed  out  in  the  special  analysis  of  new 
growths,  to  certain  of  which,  peculiar  arrangements  naturally  belong. 

Other  changes  suffered  by  blastemata,  either  in  their  primitive  state, 
or  after  having  attained  to  different  stages  of  development,  are : 

1.  Resolution  into  a  molecular  point-mass.     Blastema  breaks  up,  in 
its  primitive  state,  owing  either  to  positive  intrinsic  relations,  or  to  the 
absence  of  compulsory  extrinsic  conditions  for  its  evolution.     Or,  again, 
it  breaks  up,  after  having  already  entered  upon  a  course  of  develop- 
ment, owing  to  the  cessation  of  the  external  conditions  necessary  to  its 
maintenance  and  further  elaboration. 

In  the  state  of  disintegration,  it  may  undergo  complete  or  partial  re- 
sorption,  with  or  without  entailing  constitutional  mischief.  This  process 
is  often  attended  with  cretaceous  deposition,  often  with  fatty  conversion 
of  the  protein-substances. 

2.  The  blastemata  stop    short  at  different  stages,  retrograde,  and 


90  METAMORPHOSIS    OF    BLASTEMA. 

perish.  This  may  happen  at  any  epoch  of  their  development,  from  the 
primitive  state  upwards.  The  causes  may  be  either  inherent  in,  or 
extrinsical  to,  the  blastema.  In  some  instances  it  is  a  natural  death, 
certain  elements,  epidermis-cells,  for  instance,  dying  off,  after  having  at- 
tained their  highest  development.  This  of  course  applies  more  especially 
to  solid  blastemata.  In  their  primitive  condition,  they  part  with  their 
water,  condense,  and  shrink  into  horn-like  masses,  and  frequently  ossify. 
When  more  advanced  in  their  development, — for  example,  to  fibre — 
such  elements  waste,  and  become  reduced  to  primitive  amorphous 
blastema,  which  immediately  shrivels,  often  disengaging  calcareous  salts, 
that  is,  ossifying.  Within  the  cell  there  occurs  incrustation,  with  amor- 
phous granules  (a  kind  of  granule-cells),  or  in  stratiform  deposition. 
Here  the  blastema  has  become  bereft  of  all  faculty  for  further  develop- 
ment. 

3.  Conversion  into  fat,  occurs  both  in  primitive  blastema  and  in 
tissues,  and  it  is  frequently  accompanied  by  the  disengagement  of  salts 
of  lime, — by  cretefaction  and  ossification.  The  protein  substances 
undergo  a  transformation  into  free  fat  in  little  molecules,  and  into 
cholesterine  crystals.  To  this  conversion  both  solid  and  liquid  blaste- 
mata are  liable.  Where  cells  exist,  it  occurs  in  the  shape  of  granule- 
cells. 

Vogel  describes  it  as  a  peculiar  granule-cell  development,  established 
for  the  resorption  of  an  inflammatory  exudation.  "The  exudation," 
says  he,  "is  converted  into  nucleated  cells  of  sio^h  *°  lioth  of  a  milli- 
^metre  in  diameter.  These  cells  progressively  enlarge,  until  they  have 
attained  the  size  of  from  ^th  to  g^th  of  a  millimetre,  and  gradually  fill, 
at  first  with  a  few,  afterwards  with  very  numerous  little  dark  granules, 
until  the  cell,  originally  transparent  and  colorless,  becomes  thoroughly 
opaque,  assuming  the  brownish  or  blackish  coloration  of  its  contents,  and 
appearing  as  an  aggregation  of  granules,  which  cover  and  conceal  the 
cell-nucleus,  and  frequently  even  the  cell's  walls." 

The  concomitant  chemical  changes  consist  in  the  formation,  or  at  least 
eduction,  of  a  new  (reckoning  the  cell's  walls  and  the  cell-nucleus, — of 
a  third)  substance  within  the  granules,  possessing  the  characters  of  fat, 
and  occasionally  of  salts  of  lime.  Vogel  says,  further  on,  "  the  matured 
granule-cells  are  not  susceptible  of  ulterior  organic  development.  After 
they  have  attained  their  full  size,  and  filled  with  granule-cells,  their 
further  metamorphosis  is  a  retrograde  one.  The  cell-nuclei  disappear, 
becoming,  like  the  cell's  walls,  reabsorbed,  whilst  the  granules,  which 
alone  remain,  and  are  at  first  held  together  by  a  viscid  medium,  finally 
separate.  After  the  complete  breaking  up  of  the  granule-cells,  the 
entire  exudate  originally  present  is  converted  into  a  semi-fluid,  pulta- 
ceous  mass,  which,  with  the  aid  of  the  microscope,  is  found  to  consist  of, 
as  yet,  unchanged  granules  out  of  the  broken  granule-cells,  natant  in  a 
fluid, — the  original  serum  of  the  exuded  blood-plasma." 

With  reference  to  this  process,  which  affects  not  alone  inflammatory 
products,  but  every  kind  of  blastema,  we  have  additionally  to  state  : 

1.  The  process  of  granule-cell  development  consists  not,  we  appre- 
hend, in  a  development  of  fresh  nucleated  cells,  and  of  granules  within 
these.  The  granules  become  developed  rather  within  the  already  exist- 


HYPE  UREMIA.  91 

ing  cells,  and  also  externally  to  them  in  the  intercellular  substance. 
There  are  seen  distinct  granules,  which  here  and  there  collect  in  smaller 
or  greater  number,  and  occasionally  assume  an  investment,  not  distin- 
guishable from  the  bond-mass  by  which  they  are  held  together.  Those 
developed  within  the  cells  accumulate  and  distend  the  cell's  walls,  until 
these  give  away  and  allow  the  granules  to  escape.  This  process  may  be 
directly  witnessed,  but  it  is  further  corroborated  by  the  following  circum- 
stances : 

(a.)  Where  the  blastema  is  devoid  of  pre-existent  cells,  it  does  not 
contain  any  nucleated  granule-cells  either,  but  simply  aggregates  of 
granules ;  for  example,  in  the  fatty  conversion  of  certain  fibrinous 
coagula,  of  primitive  muscle-fibrils,  and  of  fibrous  new  growths. 

(b.)  The  exudation-cell,  the  pus-cell,  the  cancer-cell,  as  the  case  may 
be,  becomes  the  granule-cell,  which  retains  the  form  of  the  pre-existent 
cell, — for  example,  the  spherical,  wedge-like,  spindle-shaped,  fibro-elon- 
gated  granule-cell. 

2.  This  process  is,  in  point  of  fact,  the  fatty  conversion  of  the  contents 
of  the  cell.     It  is  the  counterpart  of  the  fatty  conversion  of  protein  sub- 
stances in  every  variety  of  blastema,  and  even  in  tissues  generally.     It 
gives  rise  to   emulsive    and   saponaceous    combinations,   thus   proving 
destructive  to  both  blastemata  and  new  growths,  which  latter  it  would 
indeed  render  fitted  for  resorption,  were  this  not  often  hindered  by  the 
simultaneous    disengagement  of   phosphate  of   lime  with   cholesterine 
crystals. 

These  changes  run  parallel  with  chemical  ones,  consisting  in  the  de- 
velopment of  different  kinds  of  gluten,  in  horny  conversion,  and  the  like. 

3.  Finally,  blastemata  (like  physiological  textures)  become  reabsorbed 
at  various  stages  of  development,  having  become  adapted  for  the  process 
by  a  previous  disintegration  or  fatty  conversion,  although,  in  the  case  of 
fluid  blastemata,  without  any  intermediate  change.     Solid  blastemata 
may  become  gradually  dissolved  and  fitted  for  resorption  by  blood  serum 
percolating  the  textures,  for  example,  in  solid,  fibrinous,  inflammatory 
products.     Occasionally  some  of  their  nuclei  are  left  behind,  presenting 
the  only  visible  residue  of  comparatively  extensive  blastema  masses. 

Our  next  inquiry  concerns  the  conditions  which  favor  the  throwing 
out  of  pathological  blastemata  in  particular  localities.  These  may 
consist  in  an  exudatory  process,  not  differing  from  that  which  presides 
over  the  normal  act  of  nutrition,  or  else  in  processes  which,  though  akin 
to  physiological,  are,  in  strict  parlance,  pathological.  Such  are  hyper- 
semia,  and  inflammation  in  its  numerous  modifications.  Again,  blaste- 
mata become  consolidated  within  the  vascular  system  through  the 
coagulation  of  fibrin,  as  metastases,  or  deposits. 

HYPEMMIA. 

It  is  to  be  understood  that  we  have  to  deal  only  with  local  hyperaemia 
— congestion,  so  called. 

It  consists  in  an  excessive  amount  of  blood  in  the  capillaries  of  an 
organ ;  that  is,  in  an  injected  condition  of  this  latter,  exceeding  what 
experience  has  shown  to  be  its  average.  This  is  not  possible  without 
dilatation  of  the  vessels,  nor  can  we  admit  the  existence  of  congestion 


92  HYPERS  MI  A. 

with  coarctation  of  the  vessels,  and  a  consequent  accelerated  passage 
of  the  blood  through  them,  which  some  have  designated  as  active  con- 
gestion. 

A  simple  comprehensive  view  of  the  development  of  hyperaemia  is  not 
feasible,  the  conditions  not  being  always  the  same.  It  will,  perhaps, 
suffice  to  distinguish  between  active,  passive,  and  mechanical  hyperaemia. 
We  shall  here,  however,  not  consider  these  individually — more  especially, 
the  two  former — further  than  may  be  requisite  for  the  establishment 
of  a  principle.  Their  closer  investigation  will  be  more  appropriate  under 
the  head  of  Inflammation. 

1.  Active  hypercemia  is  the  result  of  external  or   internal   stimuli 
acting  immediately  upon  an  organ,  or  reflected  to  it  from  other  organs, 
— irritating  the  sensitive  nerves,  and  thereby  causing  antagonistic  palsy 
of  the  nervi  vasorum  or  (according  to  another  theory),  evoking  an  in- 
creased afflux  of  blood,  a  preternatural  affinity  of  the  parenchyma  for  the 
blood. 

To  this  category  belong,  for  the  most  part,  those  hyperaemiae,  depen- 
dent upon  external  or  internal  causes,  which  precede  inflammations ;  most 
of  those  habitual,  constitutional  hyperaemia,  rooted  directly  in  the  nerv- 
ous system  or  in  the  blood ;  again,  those  hyperaemiae  occasioned  by 
augmented  activity,  by  overwrought  function,  or  concurrent  with  excited 
conditions  of  the  organs.  „ 

2.  Passive  Congestion  depends  upon  direct  palsy  of  the  nervi  vaso- 
rum, wherewith  is  commonly  associated  a  depressed  energy  in  the  re- 
mainder of  the  nervous  system.     The  palsy  may  originate  in  the  centres, 
or  it  may  be  peripheral.     It  is  often  determined  by  dyscrasis,  and  espe- 
cially by  the  higher  degrees  of  decomposition  of  the  blood. 

To  this  class  must  be  referred  those  hypersemise,  introductory  to  so- 
called  asthenic  inflammations,  in  organs  exhausted  by  excess  of  functional 
activity,  enfeebled  by  hyperaemiae  and  inflammation,  or  paralyzed ;  as 
also  in  those  hypostatic  hyperaemiae  of  the  lungs,  of  the  abdominal  and 
pelvic  organs,  of  the  common  integuments,  which  are  developed  under 
diminished  impulse  from  the  heart,  in  dependent  parts  of  the  body,  dur- 
ing the  progress  of  various  adynamiae  and  marasmi. 

3.  Mechanical  hyperaemiae,  namely, — 

(a.)  Hyperaemiae  arising  from  palpable  mechanical  impediments  to  the 
return  of  the  blood  through  the  veins,  or  to  the  ultimate  disgorging  of 
the  venous  trunks  into  the  heart.  The  extension  of  the  hyperaemiae 
varies  with  the  locality  of  the  impediment.  It  affects  single  organs  and 
sections  of  organs  ;  for  example,  a  portion  of  intestine  strangulated, 
invaginated  through  tension  and  compression  of  its  bloodvessels.  Or  it 
may  have  a  more  comprehensive  range  in  impermeability  of  the  liver, 
of  the  lungs,  in  stenosis  (coarctation)  of  the  heart's  valves.  The  hyper- 
aemiae occasioned  by  spontaneous  coagulation  within  the  capillaries,  by 
various  elements  obstructive  of  these  vessels,  as  pus-corpuscle,  cancer- 
cell,  injected  mercury  globule,  are  commonly  referred  to  the  same  head. 

(6.)  Hyperaemiae  ex  vacuo,  as  they  occur  in  atrophy  of  the  brain  within 
the  unyielding  skull,  or  in  the  gravid  uterus  after  rapid  delivery,  often 
to  the  extent  of  producing  hemorrhage ;  hyperaemiae  due  to  the  eccentri- 
cal rarefying  atrophy  of  organs. 


HEMORRHAGE.  93 

The  hyperaemiae  is  either  of  a  more  or  less  transitory  or  of  an  abid- 
ing nature,  of  which  latter  kind  mechanical  hyperaemiae,  from  heart 
disease  or  from  induration  of  the  liver,  present  the  most  frequent  and 
the  most  marked  examples. 

The  sequelae  of  hyperaemiae  are  multiplex,  varying  with  the  duration, 
the  repetition,  the  degree,  of  the  congestion.  Much  likewise  depends 
upon  the  character  of  the  affected  organ,  the  congestion  being  significant 
in  proportion  to  the  general  importance  of  such  organs,  and  to  the  vul- 
nerability of  its  texture.  Organs  are  prone  to  congestion  proportion- 
ately to  their  vascularity  and  to  the  degree  of  their  functional  activity. 
Under  particular  circumstances  of  life,  of  occupation,  of  civilization,  cer- 
tain organs,  such  as  the  brain  and  its  membranes,  and  the  lungs,  are 
hardly  ever  entirely  free  from  congestion.  Hyperaemiae  affects  morbid 
growths  equally  with  normal  formations. 

Intense  congestion  suddenly  developed  in  organs  essential  to  life 
(the  brain  or  lungs)  may  prove  fatal  directly,  as  so  termed  vascular 
apoplexy,  or  through  the  sudden  effusion  of  blood  serum  into  the  tex- 
tures— acute  oedema. 

High  degrees  of  congestion  occasion  laceration  of  capillaries  and  pa- 
renchymatous  hemorrhage  (apoplexy  with  bloody  extravasation)  in  the 
brain,  the  lungs,  and  other  organs. 

The  same  causes  lead,  by  an  overloading  of  the  bloodvessels,  to  abso- 
lute palsy  of  the  bloodvessels,  to  stasis,  inflammation,  and  gangrene. 

Moderate  but  habitual  or  repeated  congestion  gradually  engenders 
oedema  and  the  dropsy  of  serous  cavities — genuine  dropsy,  increased 
exudation  of  blood  plasma,  preternatural  nutrition  of  the  textures — 
hypertrophy,  augmented  secretion. 

In  this  relation,  abiding  mechanical  hyperaemiae,  from  heart  disease, 
are  worthy  of  especially  notice,  with  their  unfailing  consequences,  hyper- 
trophy of  the  glandular  abdominal  viscera  ;  preternatural  secretion  of 
the  intestinal  and  bronchial  mucous  membrane;  excessive,  saturated 
secretion  of  bile. 

Hyperaemiae  create  and  bequeath  permanent  dilatation  and  elongation 
with  coil-like  or  serpentine  deflection — properly  termed  varicosity — of 
the  bloodvessels,  as  more  particularly  exemplified  in  the  less  resilient 
veins. 

Hyperaemiae  frequently  occasion  and  obviously  accompany  the  deve- 
lopment of  various  heterologous  growths.  Finally,  in  some  organs,  a 
proportion  of  blood-pigment,  effused  with  the  plasma,  constitutes  the 
basis  of  rust-colored,  slate-gray,  bluish-black  coloration,  as  in  the  lungs  or 
on  the  intestinal  mucous  membrane. 

Organs  attacked  by  a  high  degree  of  hyperaemia  present  different  shades 
of  dark  red,  become  swollen,  loosened  in  texture,  and  consequently  friable, 
lacerable.  In  organs  of  a  porous  spongy  texture,  the  swelling  seems 
due  to  a  bloated  condition  of  the  tissue  itself. 

HEMORRHAGE. 

^emorrhage  consists  in  the  extravasation  of  blood  bodily,  and  in  its 
entirety,  from  the  bloodvessels,  consequent  upon  a  breach  of  their  con- 


94  HEMORRHAGE. 

tinuity.  Herein  it  differs  from  red  effusions  resulting  from  the  transuda- 
tion  through  the  parietes  of  vessels  of  blood  serum,  which,  owing  to  various 
changes  of  admixture,  has  taken  up  blood  pigment.  Hemorrhage  occurs 
either  within  textures,  when  it  is  with  reference  to  its  attendant  para- 
lysis, somewhat  inappropriately  termed  apoplexy ;  or  else  within  natural 
or  preternatural  cavities  or  canals ;  for  example,  in  serous  sacs,  in  muco- 
membranous  cavities  or  canals,  pus-reservoirs,  &c.  The  two  kinds  fre- 
quently coexist. 

Heterologous  growths  are,  in  the  same  degree  as  normal  formations, 
subject  to  hemorrhage,  those  at  least  which  are  highly  vascular ;  as,  for 
instance,  adventitious  membranes,  carcinoma  (in  a  high  degree),  the  inte- 
rior of  cysts,  &c. 

Hemorrhage  depends  upon  various  causes,  the  most  common  cause 
being,  as  before  stated,  a  breach  of  continuity  in  the  bloodvessels. 

Apart  from  hemorrhages  produced  by  external  injury  inflicted  upon 
bloodvessels,  whether  alone  or  in  conjunction  with  other  formations, 
those  resulting  from  the  following  momenta,  more  especially  capillary 
(parenchymatous)  hemorrhages,  possess  a  high  degree  of  interest. 

1.  Hemorrhage  the  result  of  intense  hyperaemia,  of  whatever  kind. 
Thus,  active  hypersemia  has  a  marked  tendency  to  create  bronchial 
hemorrhage,  passive  hypersemia  uterine  hemorrhages,  hypergemia  from 
mechanical  causes,  in  particular  the  bronchial  and  intestinal  hemorrhages 
that  result  from  heart  disease,  and  the  cerebral  hemorrhages  induced  by 
a  vacuum  within  the  skull. 

Finally,  the  excessive  accumulation  of  blood  determines  rupture  of  the 
capillaries. 

2.  Another  step  conducts  us  to  hemorrhage  as  occurring  during  the 
progress  of  inflammation,  namely,  in  the  stages   of  congestion  and  of 
stasis.     In  this  combination  we  have  hemorrhagic  inflammation,  and  the 
in  many  respects  remarkable  exudation  designated  hemorrhagic.     Here, 
as  in  simple  hyperaemia,  the  hemorrhage  is  unfailing,  and  considerable 
in  proportion  to  the  extent  of  the  congestion  and  stasis,  as  also  to  the 
delicate,  lax,  and  vulnerable,  nature   of  the  implicated  texture.     Any 
one  of  these  influences  may  predominate  to  a  various  extent.     There  are 
organs  in  which,  owing  to  the  nature  of  the  texture,  inflammation  never 
takes  place  without  hemorrhage — for  instance,  the  brain,  the  lungs,  many 
heterologous  formations,  and  especially  exudates  undergoing  a  change  of 
structure,  and  loose  cancerous  textures.     The  hemorrhage  is  capillary. 

3.  Hemorrhage  from  the  laceration  of  vessels,  produced  in  atrophied 
organs  by  the  laxity  and  diminished  resistance  of  surrounding  textures 
— apoplexy  of  the  decrepit  uterus. 

4.  Hemorrhage  from  the  spontaneous  laceration  of  organs  diseased  in 
texture,  pulpy  and  friable — laceration  of  the  heart. 

5.  Hemorrhage  from  laceration  of  vessels   consequent  upon  impaired 
texture  of  their  coats,  with  or  without  dilatation  of  their  calibre.     It 
affects  the  smallest  bloodvessels  as  readily  as  the  main  trunks,  and  more 
especially  the  arteries.     Other  coincident  causes — hyperaemia,  for  ex- 
ample— greatly  favor  its  occurrence. 

6.  Hemorrhage    consequent   upon    the   destruction   of  bloodvessels 
by  ulceration,  or  by  contact  with  a  free  acid,  as  in  softening  of  the 
stomach. 


HEMORRHAGE.  95 

It  is  questionable  whether,  and  in  what  way,  dyscrasial  states  can 
give  rise  to  hemorrhage.  A  relaxation  of  the  coats  of  bloodvessels  suffi- 
cient to  admit  of  the  passage  through  them  not  only  of  plasma,  but  also 
of  blood-corpuscles,  is  by  no  means  proved,  and  its  assumption,  to  explain 
the  hemorrhage  occurring  in  scurvy  or  typhus,  needless.  The  sponta- 
neous hemorrhage  arising  in  the  progress  of  such  maladies,  is  the  result 
either  of  local  hypersemia  and  inflammation,  into  which  those  general 
diseases  have  resolved  themselves,  or  else  of  preternatural  expansion 
(increased  volume)  of  the  blood  itself,  and  of  the  consequent  rupture  of 
bloodvessels  in  the  looser  textures,  such  as  the  gums,  the  mucous  mem- 
branes, and  the  lungs.  Hence  the  occurrence  of  hemorrhage  in  several 
organs  simultaneously,  and  again  the  predominant  invasion  of  a  few  par- 
ticular organs.  That  hemorrhage,  having  once  set  in  under  such  cir- 
cumstances, is  apt  to  become  excessive,  is  due,  without  any  doubt,  to  the 
slender  coagulability  of  the  dyscrasial  blood. 

Hcemorrhophilis — habitual  hemorrhage — depends,  so  far  as  we  at 
present  know,  upon  a  preternaturally  delicate  and  vulnerable  structure 
of  the  coats  of  the  vessels,  coupled  with  a  thin,  watery,  condition  of  the 
blood. 

Hemorrhage  greatly  varies  in  intensity.  Its  character  is  to  be  esti- 
mated not  merely  by  the  quantity  of  blood  thrown  out  either  externally 
or  into  internal  cavities  and  canals,  nor  by  the  degree  of  anaemia  that 
follows,  but  also,  where  the  parenchyma  of  organs  is  its  seat,  by  the 
anatomical  condition  in  which  we  find  the  diseased  parenchyma.  In 
slight  hemorrhage,  the  texture  appears  here  and  there  dotted  or  streaked 
with  extravasated  blood, — Capillary  apoplexy.  As  the  hemorrhage  in- 
creases, these  dots  or  streaks  become  more  crowded,  the  parenchyma, 
more  turgid,  until  its  interstices  and  cavities  having  at  length  become 
uniformly  surcharged  with  blood,  it  appears  throughout  red.  Or,  where 
the  blood  has  become  coagulated,  the  rough  texture  seems  as  if  converted 
into  a  blood  placenta,  whilst  a  diminished  coherence  of  its  molecules, 
and  numberless  lesions  of  continuity  have  rendered  it  friable,  easily  torn 
[mucous  membrane,  lung].  Such  is  the  condition  of  the  denser,  more 
resisting  textures ;  in  those  of  a  more  lax  nature,  or  where  the  hemor- 
rhage has  been  sudden  and  violent,  the  texture  is  completely  swamped 
and  crushed  into  a  red  pulp  of  various  shades,  or  else  more  or  less  lacera- 
tion of  texture  has  taken  place,  and  the  gap  so  occasioned  become  the 
recipient  for  the  extravasated  blood — apoplectic  foyer. 

The  extravasated  blood  varies  in  deportment  according  as  it  is  circum- 
stanced subsequently  to  its  extravasation.  Certain  influences  cause  it  to 
undergo  rapid  and  unusual  changes :  for  example,  in  the  stomach  and 
intestines,  black  coloration  and  liquefaction  of  its  fibrin,  through  the 
influence  of  gastric  and  enteric  acid. 

Blood  poured  out  into  cavities  and  canals,  or  into  textures,  is  either 
fluid  or  in  various  phases  of  coagulation.  Of  these  phases,  coagulation 
with  central  or  peripheral  encysting  separation  of  fibrin  is  the  most 
important,  owing  to  the  increased  impediment  which  it  offers  to  the  pro- 
cess of  absorption. 

The  immediate  effects  of  hemorrhage,  besides  the  anaemia  consequent 
upon  great  effusion,  either  out  of  the  body,  or  into  its  cavities,  are  lesion 


96  HEMORRHAGE. 

of  continuity  in  textures,  in  the  shape  of  the  swamping,  crushing,  or 
extensive  laceration  before  referred  to — impaired  or  destroyed  function, 
paralysis  of  the  organ  affected — cerebral,  muscular  hemorrhage.  A  less 
immediate  effect  is  the  inflammation  of  surrounding  textures,  occasioned 
by  actual  injury,  and  by  the  irritation  of  the  extravasated  fluid,  as  a 
foreign  body,  with  eventual  organization  of  the  products  effused,  callous 
condensation  of  the  nether  layer,  and  capsular  isolation  of  the  hemor- 
rhagic  clot.  Inflammation,  resulting  in  purulent  and  ichorous  products, 
in  parts  broken  up  by  hemorrhage,  is  of  rarer  occurrence. 

Hemorrhage  is  both  in  itself,  and  in  its  results,  of  significance  com- 
mensurate with  the  importance  of  the  organ  affected. 

The  cure  of  hemorrhage  is  a  process  simple  or  complex  in  a  degree 
corresponding  to  the  amount  of  blood  effused,  to  its  character  as  coagu- 
lable  fluid,  and  to  the  extent  of  the  injury  suffered  by  the  parenchyma. 

Slight  hemorrhage  is  readily  cured  through  resorption  of  the  effused 
fluid,  enabling  the  distended  textures  to  recover  their  resiliency.  The 
liberated  red  pigment,  however,  frequently  resists  absorption,  even  in 
slight  hemorrhage,  remaining  strewn,  for  the  most  part  in  a  state  of 
minute  molecular  dispersion,  over  membranous  formations,  or  between 
the  elementary  parts  of  a  texture,  as  a  brown  or  black  pigment. 

The  remedial  process  is  difficult  and  complicated  proportionately  to 
the  amount  of  blood  extravasated,  to  the  resulting  destruction  of  texture, 
and  to  the  solidity  of  the  coagulated  fibrin  as  a  central  or  a  peripheral 
secretion  from  the  fluid  thrown  out.  It  is  a  process  of  slow  gradation, 
involving  the  changes  produced  not  only  in  the  effused  blood  with  its 
red  pigment  and  its  fibrin,  but  also  in  the  surrounding  textures.  These 
changes  occur  simultaneously,  and  we  have  frequent  opportunities  of 
observing  them  in  areolar  tissue,  in  muscle,  and  especially  in  the  brain. 

The  crushed  and  disorganized  texture  within  the  walls  of  the  foyer, 
together  with  the  extravasate  itself,  undergoes  liquefaction,  at  the  same 
time  that  hypersemia  and  stasis  become  developed  in  the  adjacent  texture- 
layer.  The  medium  is  probably  almost  exclusively  supplied  by  the  blood 
serum  of  the  extravasated  fluid  which  undergoes  many  changes  in  com- 
position adapting  it  for  the  liquefaction  of  the  different  substances ; 
namely,  the  solidified  fibrin  and  the  remaining  elements  proper  to  the 
effusion — blood-globules,  nucleated  and  cell-formations,  debris  of  tissues. 
How  important  a  part  the  liberation  of  adipose,  and  of  saline  substances 
out  of  their  primitive  combinations  herein  plays,  is  sufficiently  attested 
by  microscopic  analysis.  The  blood-pigment  incurs  a  special  change. 
It  is  converted,  partly  within  the  blood-corpuscles,  partly  extraneously 
to  them,  into  a  brown,  rusty  yellow,  or  into  a  blackish-brown,  or  a  black 
pigment.  This  is  shown  as  well  in  the  form  of  spherical  corpuscles, 
which  resemble  blood-globules  and  are  frequently  seen  accumulated  in 
compact  congeries,  as  also  in  the  shape  of  elementary  granules  (granu- 
lated pigment),  either  discrete  or  in  circular  groups.  These  are  com- 
monly free,  but  now  and  then  inclosed  within  cells,  or  suspended  from 
little  prismatic  crystals  of  ammonio-phosphate  of  magnesia.  Together 
with  them  is  found,  at  the  part  involved,  fat  in  a  free  state,  fat  in  the 
form  of  little  black-edged,  discrete  or  aggregate  molecules,  of  limpid 
drops,  of  cholesterine  crystals.  Again,  there  are  found  elementary 


HEMORRHAGE.  97 

molecules  down  to  the  minutest  pulverulent  molecular  mass,  consisting 
of  minutely  subdivided,  suspended  fibrin,  albumen,  and  fat,  with  calca- 
reous salts.  Finally,  we  have  amorphous,  membranaceous,  stratiform 
coagula,  nuclei,  and  blood-disks  (the  as  yet  integral  elements  of  the  effu- 
sion), and  amongst  them  all  detritus  of  the  involved  texture. 

In  this  manner  the  greater  portion  of  the  hemorrhagic  effusion  would 
have  become  fitted  for  resorption.  The  process  is,  however,  impeded  at 
this  juncture,  by  the  inflamed  condition,  and  at  a  later  period  by  the 
hardened  character  of  surrounding  textures. 

Hence  the  ulterior  metamorphosis  of  the  effused  mass,  namely,  its 
progressive  thinning  and  clarifying  into  a  mere  pale  buff,  or,  it  may  be, 
colorless  liquid. 

What,  amongst  other  things,  has  become  of  the  pigment  ?  Partially 
it  may  have  perished  amid  the  unknown,  final  conversions  of  the  fluid 
above  characterized.  To  some  extent,  however,  it  is  preliminarily  taken 
up  into  a  formation  which, — derived  from  the  coagulable  contents  of  the 
effused  fluid — invests  the  walls  of  the  foyer. 

This  colored,  soft,  jelly-like,  loosely  adherent  lining,  eventually  be- 
comes endowed  with  a  minutely  fibrillated  structure,  and  even  with  blood- 
vessels, and  is  at  length  converted  into  a  delicate,  and,  if  the  pigment 
be  destroyed,  into  a  colorless  membrane,  resembling  a  serous  tunic. 

Meanwhile,  the  inflammatory  process  has  engendered  in  the  walls  of 
the  foyer  products  which  serve,  in  the  shape  of  a  nucleated  blastema  (to 
be  afterwards  developed  into  fibrin  texture  of  various  kinds,  and,  into 
areolar  tissue),  to  condense  and  harden  the  textures.  Thus,  the  original 
hemorrhagic  foyer  is  changed  into  a  capsule  or  cyst,  which,  when  it 
occurs  in  the  cerebrum,  is  termed  apoplectic  cyst. 

This  cyst  is  susceptible  of  diminution,  and  eventual  closure,  through 
resorption  of  its  contents, — of  closure  to  a  cicatrix  which  often  contains 
a  certain  kernel  consisting  of  the  aforesaid  residuary  pigment. 

It  must  be  confessed,  however,  that  the  complete  closure  of  the  cyst 
is  a  work  of  time  and  difficulty.  This  is  intelligible  from  the  slender 
absorbent  faculty  of  the  surrounding  textures  in  their  condensed  and 
hardened  condition.  Occasionally,  special  obstacles  stand  in  the  way  of 
this  process  of  reduction  ;  for  example — 

1.  Great  extent  of  the  hemorrhagic  foyer,  and  of  the  resulting  cyst. 

2.  A  vacuum,  created  either  through  original  retraction,  or  through 
subsequent  wasting  of  the  texture  involved,  in  muscles  and  especially  in 
the  cerebrum.     In  the  brain,  indeed,  a  later  supplementary  enlargement 
may  take  place  in  the  apoplectic  cyst,  as  an  expletive  of  the  vacuum 
created  within  the  skull  by  consecutive  atrophy  of  the  cerebral  organ ; 
for  the  internal  capsular  membrane  is,  by  reason  of  its  vascularity, 
adapted  alike  for  secretion  and  for  absorption. 

3.  A  very  remarkable  obstacle  to  the  collapse  and  closure  of  the  cyst 
consists  in  the  secretion  of  fibrin  in  the  shape  either  of  central  bulky,  or 
else  of  peripheral  isolating  coagula,  for  the  most  part  tinged  by  no  in- 
considerable proportion  of  embodied  blood-corpuscles.     These  coagula, 
being  originally  very  dense,  and  retaining  their  solidity  even  when  con- 
verted into  a  fibrous  texture,  resist,  when  central,  the  liquefaction,  when 
peripheral  and  encysting,  the  resorption  of  their  contents. 

VOL.  I.  7 


98  ANEMIA  —  INFLAMMATION. 

Certain  cases  offer  various  exceptions  to  the  processes  hitherto  de- 
scribed. Thus,  some  cysts  having,  in  spite  of  the  peripheral  encysting 
coagula,  parted  with  their  blood-serum  by  early  resorption,  are  found 
replete  with  a  dark-colored,  inspissated,  dry  blood-plug ;  or  else  with 
fibrinous,  stratiform,  villous  masses,  developed  out  of  the  partially  ab- 
sorbed vehicle. 

The  frequency  of  hemorrhage  varies  greatly  in  the  different  textures 
of  the  organs.  A  scale  of  frequency  is  indeed  but  of  very  limited  use, 
since  hemorrhage  is  the  result  of  various  disturbances,  and,  in  most 
instances,  of  the  concurrence  of  several.  Generally  speaking,  hemor- 
rhages of  the  brain  and  of  the  bronchial  mucous  membrane  are  distin- 
guished by  their  frequency ;  those  of  serous  membranes  are  very  rare,  if 
we  except  the  cerebral  arachnoid  sac. 

It  was  signified  at  the  outset,  that  the  mere  exudation  of  colored  (red) 
serum,  devoid  of  blood-corpusles,  is  perfectly  distinct  from  hemorrhage. 
It  is  found  as  so  called  petechiae  (ecchymoses)  in  all  textures,  and  in 
serous  and  mucous  cavities  as  colored  effusion.  It  is  due  to  decomposi- 
tion of  the  blood. 

ANJEMIA. 

The  chapter  on  hyperaemia  naturally  leads  to  a  passing  consideration 
of  the  opposite  state,  namely  ancemia.  Just  as  we  have  before  treated 
only  of  local  hyperaemia,  we  shall  here,  in  like  manner,  limit  ourselves 
to  the  subject  of  local  anaemia.  It  comprehends  both  oligaemia,  or  an 
insufficient  measure  of  blood  in  relation  to  what  experience  has  shown 
to  be  its  just  standard,  and  true  anaemia  of  an  organ. 

It  is  present  under  various  conditions  : 

1.  As  the  partial  manifestation  of  general  anaemia. 

2.  As  the  consequence  of  hyperaemia  of  one  or  more  other  organs. 

3.  As  the  result  of  coarctation  and  closure,  or  orificial  obstruction  of 
the  vascular  trunk  supplying  the  diseased  organ  or  part,  pending  the 
establishment  of  a  compensating  collateral  circulation. 

4.  As  the  effect  of  external  or  internal  pressure  upon  an  organ,  and 
its  consequent  inadequate  injection  ;  anaemia  of  the  lungs  from  pleuritic 
effusion  ;  anaemia  of  textures  the  interstices  of  which  are  filled  up  with 
morbid  products,  as  in  hepatization  of  the  lungs,  in  fatty  infiltration  of 
the  liver. 

5.  As  a  consequence  of  decay  of  the  vascular  apparatus  of  an  organ 
affected  with  atrophy,  whether  primary  or  secondary,  more  especially 
atrophy  with  condensation  (concentrical  wasting). 

The  effects  of  anaemia  are  pallor,  collapse,  and  shrivelling  of  the  tex- 
tures, weakening  and  eventual  extinction  of  their  function. 

Anaemia  is  momentous  proportionately  to  the  vital  importance  of  the 
diseased  organ,  and  to  its  exigencies  with  respect  to  the  supply  of  blood. 
Thus,  anaemia  of  the  brain,  of  the  lungs,  of  muscle,  is  of  the  highest 
import. 

INFLAMMATION,    PHLOGOSIS. 

This  pathological  process  is  of  paramount  interest,  not  only  on  account 
of  its  great  frequency,  and  of  the  great  variety  of  external  causes  by 


INFLAMMATION.  99 

which  it  is  called  forth,  but  also  as  being  that  in  which  most,  and  in  a 
certain  sense  all,  general  diseases  become  localized.  It  is  a  process 
which  leads  incontinently  to  the  most  various  and  most  extensive  new 
growths,  and  associates  itself,  equally  often,  to  other  anomalous  forma- 
tive efforts.  In  fine,  it  is  a  process  which,  on  the  one  hand  productive, 
on  the  other  hand  frequently  proves  destructive  of  both  normal  and 
anomalous  formations. 

The  inflammatory  process  is  capable  of  being  experimentally  called 
forth  and  observed,  in  all  its  phases,  in  transparent  textures.  Thus 
studied,  it  has  furnished  the  groundwork  for  the  most  varied  interpreta- 
tions, but,  at  the  same  time,  for  researches  respecting  other  exudatory 
processes.  Nor  have  these  experiments  failed  in  a  certain  measure  to 
elucidate  the  connection  that  prevails  between  blastema  and  the  endo- 
genous formative  processes  carried  on  in  the  blood  itself. 

We  seek  not  to  deprive  this  process  of  its  time-honored  name,  inflam- 
mation, because  it  has  become  naturalized  in  science  beyond  all  others. 
It  is  applicable  enough,  if  in  using  it  we  simply  dismiss  the  theories 
which  first  led  to  its  adoption.  It  comprehends  the  entire  process,  and 
the  efforts  made  to  designate  the  latter  differently  have  utterly  failed. 
Andral's  hypersemia,  and  Eisenmann's  stasis  have  not  advanced  the 
subject  by  a  single  step. 

It  is  impossible  to  define  inflammation  suitably,  owing,  on  the  one 
side,  to  our  imperfect  knowledge  of  its  proximate  causes ;  and,  on  the 
other,  to  the  complex  nature  of  its  consecutive  phenomena.  These 
latter,  variously  modified  in  type,  point  to  processes  equally  varied, 
whilst  they  at  the  same  time  furnish  the  most  striking  analogies  with 
other  processes  which  issue  in  exudation  (production  of  blastema). 

Let  us  now  proceed  to  a  descriptive  examination  of  the  phenomena 
which  constitute  so  many  stages  of  the  process,  a  due  regard  being  had 
to  the  results  of  experiment,  that  is,  to  the  observation  of  the  inflamma- 
tory process  as  artificially  called  forth  in  animals.  And  in  this  descrip- 
tion, together  with  the  analytical  remarks  annexed  to  it,  we  will  take 
for  our  basis  the  so-called  pure,  legitimate,  inflammation,  which  yields 
essentially  a  coagulable,  fibrinous,  plastic  product,  as  developed  in 
sound  organisms  without  the  co-operation  of  a  pre-existent  dyscrasis, 
and  simply  as  a  consequence  of  moderate  local  stimulation ;  such  being 
the  most  marked  of  any  in  its  manifestations  and  stages. 

The  phenomena  of  the  inflammatory  process  present  the  following 
sequence. 

1.  The  moderate  influence  of  mechanical  or  chemical  stimuli  is  fol- 
lowed by  contraction  of  the  capillaries,  and  simultaneous  quickening 
of  the  blood-stream  through  them.     This  phenomenon  may  be  wanting 
as  an  effect  of  most  causes  of  inflammation  in  the  human  species ;  and 
even  in  experiments  upon  animals  it  is  either  transitory  or  entirely  absent 
if  the  stimuli  applied  be  potent. 

Contraction  of  the  vessels  is  succeeded  sooner  or  later  by — 

2.  Dilatation  of  the  capillaries,  if  this  be  not,  indeed,  the  very  first 
cognizable  phenomenon.     Unlike  contraction,  it  is  invariably  present, 
readily  seen  both  in  the  living  animal  and  in  the  dead  subject,  as  is,  in 
like  manner,  the  simultaneous  loading  of  the  vessels  with  an  increase  of 


100  INFLAMMATION. 

blood.  It  determines  capillary  injection,  and  therefore  the  redness  of 
injection  proper  to  inflamed  textures. 

This  dilatation  of  the  vessels  is  attended  by  a  retarding  of  the  blood- 
stream, which  sooner  or  later,  although  not  always  visibly,  merges  in  an 
oscillating  movement  of  the  blood  in  the  capillaries.  The  contained 
blood-columns  move  forward  and  backward  by  turns,  the  onward  move- 
ment, however,  predominating.  The  blood-corpuscles  begin  to  adhere 
to  one  another,  like  rolls  of  coins,  the  outer  linear  layer  of  plasma  (the 
lymph  space)  within  the  vessel  still  remaining  unchanged. 

This  twofold  proceeding  establishes  the  stage  of  congestion. 

3.  Hereupon  ensues,  sometimes  so  rapidly  as  to  prevent  the  retard- 
ment of  the  blood-stream  and  its  oscillation  from  being  noticed,  stag- 
nation of  the  blood-stream, — stasis.      The  bloodvessels  are  completely 
filled  up  with   blood-corpuscles,  so  that   the   transparent,  so  termed, 
lymph  space,  near  the  circumference  of  the  vessel  and  before  occupied 
by  plasma,  has  vanished.      Meanwhile  the  blood-corpuscles  have  as- 
sumed greater  intensity  of  color,  have  become  flattened,  contracted, 
and  firmly  glued  to  each  other,  and  to  the  vessel's  walls,  so  as  to  form  a 
homogeneous  red  mass,  with  irregular  translucent  intervals. 

The  nuclei  and  nucleated  cells  (so-called  lymph-globules  and  colorless 
blood-corpuscles)  have  increased  in  number  to  an  extraordinary  extent, 
often  adhering  together  in  groups  aonnected  by  delicate  transparent 
coagula,  and  forming  either  thus,  or  singly,  the  aforesaid  translucent 
intervals.  The  blood  has  assumed  a  dark  tile-colored  aspect,  verging 
upon  cherry-red. 

In  the  preceding  stage  (see  hyperasmia),  as  well  as  in  this,  two 
notable  phenomena  are  witnessed,  namely : 

(a.)  Laceration  of  bloodvessels,  and  extravasation  into  the  textures, 
or  into  the  free  spaces, — lung-cells ;  muco-membranous  cavities  and 
canals;  serous  sacs.  The  hemorrhage  is  frequent  and  considerable, 
proportionately  to  the  degree  of  congestion  and  stasis,  and  also  to  the 
delicacy  and  the  textural  looseness  of  the  diseased  part.  For  the  most 
part  it  takes  the  form  of  capillary  apoplexy,  and  only  in  very  delicate 
normal  and  anomalous  textures,  as,  for  example,  the  brain  or  encepha- 
loid  cancer,  the  form  of  the  isolated  clot. 

(b.)  Transudation  of  blood-serum  through  the  thinned  bloodvessel 
walls  into  the  parenchyma,  and  from  membranous  expansions  into  the 
cavities  and  canals  of  which  they  form  the  lining.  This  implies,  in  the 
parenchymata,  pervading  moisture, — in  expansive  structures,  diffuse 
exudation  or  circumscribed  accumulations  beneath  the  epidermis, — for 
example,  in  burns,  in  vesication  artificially  called  forth,  in  erysipelas, 
and  the  like.  The  exuded  serum  resembles  essentially  blood-serum, 
only  that  it  is,  for  the  most  part,  less  rich  in  albumen.  This  pheno- 
menon often  merges  at  once  in  the  exudatory  process  next  succeeding, 
the  two  acts  being  simultaneous. 

4.  The  step  to  which  stasis  ultimately  leads  is  genuine  effusion,  that 
is,  the   exudation  of  blood-plasma,  a  fluid  holding  in  solution  fibrin, 
albumen,  and  salts.      It  is  thrown  out  into  parenchymata,  filling  up 
their  interstices  to  a  various  extent,  either  as  a  fluid,  or  as  a  more  or 
less  solidified  product.     Or,  again,  it  is  partially,  or,  it  may  be,  wholly 


I X  F  L  A  M  M  ATIOJX:'*  101 

expended  upon  the  free  surfaces  of  natural  cavities  and  canals,  or  of 
such  as  have  arisen  out  of  the  previous  transudation  of  seruni,  for 
example,  in  vesication  of  the  epidermis,  or  in  antecedent  suppuration  of 
textures, — in  abscess  cavities. 

With  exudation,  the  inflammatory  process  is  to  be  looked  upon  as 
closed.  It  is  immediately  followed  by  an  endosmotic  current  of  the 
serous  portion  of  the  effusion,  causing  the  blood-corpuscles  to  float  in  a 
thinner  medium,  to  exchange  their  now  flattened  for  a  more  spherical 
shape,  to  become  separated,  to  part  with  a  portion  of  their  pigment,  and 
finally,  by  dint  of  a  returning  resilience  in  the  bloodvessels,  to  move, 
conjointly  with  the  aforesaid  form-elements,  onward  again  in  the  circu- 
lating stream. 

We  have  now  furnished  the  reader  with  a  substantial  description  of 
the  several  acts  which  make  up  the  process  of  inflammation.  We  shall 
further  endeavor  to  show  how  these  may  be  reconciled  with  the  present 
standard  of  pathological  science. 

1.  The  first  experimental  phenomenon  adverted  to,  namely,  contrac- 
tion of  the  capillaries,  with  acceleration  of  the  blood-stream,  has  been 
stated  to  be  inconstant,  and   indeed   absent  altogether,  when  potent 
stimuli  have  been  used  in  the  first  instance.     Where  it  does  occur,  it  is 
to  be  regarded  as  a  vital  phenomenon.     The  contraction  of  the  blood- 
vessels is  moreover  independent  of  any  simultaneous  collapse  of  the 
parenchyma,  like  that  produced,  for  example,  by  the  action  of  cold. 

2.  The  dilatation  of  bloodvessels  and  the  retardment  of  the  blood- 
stream are,  on  the  other  hand,  constant  and  essential.     The  very  fact  of 
their  being  so  commonly  the  primitive  phenomena,  or  at  any  rate  of 
their  succeeding  very  rapidly  to  a  previous   contraction,  refutes  the 
notion  of  their  consisting  in   a  secondary  relaxation,  resulting   from 
exhaustion.     With  these,  and  with  the  subsequent  stasis,  the  theories 
of  inflammation  hitherto  advanced  are  mainly  concerned. 

Henle  reduces  these  to  an  attraction-theory,  and  to  a  neuropatho- 
logical  theory. 

(a.)  The  attraction-theory  refers  the  essential  phenomena  of  inflam- 
mation to  an  augmented  aflinity  between  the  parenchyma  and  the  blood, 
and  especially  to  an  anormal  attraction  of  the  blood,  and  of  the  blood- 
corpuscles  in  particular,  by  the  affected  parenchyma.  It  assumes  the 
retardation  of  the  blood-stream,  and  the  crowding  together  of  the  blood- 
disks  to  be  the  primary — the  dilatation  of  the  capillaries  a  secondary 
phenomenon.  It  explains  even  the  stasis  as  a  continued  increment  of 
that  attraction. 

The  augmented  attraction  is  effected  through  the  intervention  of  the 
nerves,  and  either  by  direct  influence  upon  the  peripheral  nerves,  or 
else  by  reflection  from  the  centres  of  the  nervous  system. 

The  attraction-theory  carries  the  problem  of  congestion  and  stasis  a 
step  farther,  without  solving  it.  Together  with  its  common  attribute, 
namely,  an  increased  afflux  of  blood  to  the  diseased  part,  as  due  to  a 
dilatation,  and  to  a  more  frequent  contraction  of  the  afferent  artery,  it 
has  been  met  by  many  valid  objections.  It  is  only  the  stasis  and  in- 
flammation engendered  by  a  pre-existent  dyscrasis  that  can,  provided 
the  attraction  be  not  limited  to  the  blood-corpuscles,  but  embrace  the 


102  INFLAMMATION. 

diseased  plasma,  warrant  the  conclusion  of  a  preternaturally  strong 
affinity  between  blood  and  parenchyma.  There  would  be  some  analogy 
between  such  a  localization  of  general  disease,  and  the  indwelling  rela- 
tion of  secreting  parenchymata  to  certain  normal  or  anomalous  ingre- 
dients of  the  blood.  But  these  inflammations,  like  the  rest,  are  aptly 
expounded  in  the  neuropathological  theory. 

The  neuropathological  theory,  on  the  contrary,  assigns  to  the  nerves 
an  important  part,  and  ascribes  the  accumulation  of  the  blood  to  the 
dilatation  of  the  bloodvessels,  this  being  set  down  as  the  primary — that 
as  the  consecutive  phenomenon. 

The  dilatation  of  the  vessels  is  the  consequence  of  paralysis  of  the 
nerves.  Respecting  the  cause  and  the  conditions  of  this  paralysis, 
there  exist  two  different  opinions. 

According  to  Henle,  an  antagonistic  relation  prevails  between  the 
states  of  irritation  of  the  sensitive  nerves,  and  of  the  nerves  of  the 
bloodvessels :  a  high  degree  of  inflammatory  irritation  in  a  sensitive 
nerve  producing  a  state  of  depression — in  a  word,  paralysis  of  the 
implicated  bloodvessel  nerves. 

According  to  Stilling,  the  sensitive  and  the  bloodvessel  nerves  bear, 
on  the  contrary,  a  direct  sympathetic  relation  to  each  other.  He 
assumes  a  continual  reflex  action  to  be  kept  up  by  the  sensitive,  upon 
the  bloodvessel  nerves,  whereby  tke  tone  of  the  latter  is  sustained. 
With  paralysis  of  the  former,  the  tone  of  the  latter  is  destroyed; 
whereas  by  excitation  of  the  former  their  reflective  power  is  augmented, 
and  the  tone  of  the  latter  thereby  raised.  In  accordance  with  this 
reciprocity,  two  different  kinds  of  inflammation  are  made  out. 

Griesinger  was  led  to  the  adoption  of  a  similar  view,  imagining  pain 
to  result  from  a  qualitative  disturbance  of  the  texture  of  the  nerve. 

Against  this  hypothesis  it  is  to  be  objected  that  a  continued  reflex 
action  of  the  nerves  of  sensation  upon  those  of  the  bloodvessels  as  a 
necessary  condition  for  the  undisturbed  function  of  those  vessels  is  not 
proved ;  and  that  the  assumption  of  two  different  characters  of  inflam- 
mation, involves  both  a  contraditio  in  adjecto,  and  a  disregard  of  the 
results  of  observation.  An  inflammation  with  augmented  tone  of  the 
bloodvessels  cannot  exist,  and  this  admitted,  inflammation  with  and 
through  paralysis  (diminished  tone),  must  invariably  ensue  from  in- 
fluences paralyzing  to  the  sensitive  nerves.  This  is,  however,  opposed 
to  daily  experience. 

Our  own  opinions  accord  with  those  of  Henle,  whose  theory  we  shall 
therefore  adopt  as  the  groundwork  of  any  future  remarks  on  this  subject. 

Even  here  the  causal  momentum  influences  the  peripheral  nerves, 
producing  either  at  the  spot  itself,  or  through  the  intervention  of  the 
nervous  centres,  in  other  sympathetically  allied  structures,  excitation 
and  depression.  Or  again,  the  influence  affects  the  nerves  within  the 
centres,  the  impression  being  conveyed  from  thence  to  the  corresponding 
peripheral  organs. 

The  stasis  is  not  accounted  for  in  the  neuropathological  theory.  It 
is,  indeed, — 

3.  Not  intelligible  upon  the  ground  of  paralysis  and  dilatation  of 
the  bloodvessels,  even  though  [as  we  must  admit  a  certain  off-flowing  to 


INFLAMMATION".  103 

take  place  to  the  veins]  we  may  not  regard  the  stasis  as  an  absolute  one. 
For  our  own  part,  we  hold  stasis  to  be  dependent  upon  the  following 
momenta : 

(a.)  The  cohering,  crowding,  and  impaction  of  the  blood-disks  within 
the  capillaries,  the  blood-plasma  being  partly  withdrawn  into  the  veins. 

(b.)  The  thickening  of  the  plasma,  and  its  saturation  with  fibrin  and 
albumen,  owing  to  the  transuding  of  blood-serum  through  the  distended 
and  thinned  bloodvessel  walls. 

(c.)  The  accumulation  of  the  colorless  globules — that  is,  nucleus  and 
cell-formations — along  with  the  blood-corpuscles,  their  conglutination, 
and  the  delicate  transparent  fibrinous  coagula  collaterally  developed. 
This  is,  perhaps,  the  most  important  stage  in  the  inflammatory  process, 
as  at  once  illustrating  the  stasis  itself,  and  embracing  the  plastic  pro- 
cesses in  which  the  blood  engages  when  arrived  at  this  point.  A  line 
of  distinction  is  thus  drawn  between  the  inflammatory  process,  and  a 
simple  process  of  exudation.  The  form-elements  adverted  to  are  not 
merely  washed  together  within  the  range  of  the  stasis ;  they  are  new 
creations  out  of  the  blood  so  arrested,  which  at  the  same  time  undergoes 
other  remarkable  changes.  Thus  it  is  of  a  dark  red,  with  a  tile-colored 
shade,  contains  red  flocculent  particles  of  cruor,  visible  to  the  naked  eye, 
teems  with  the  aforesaid  elementary  bodies,  and  with  coagula,  most  of 
which  latter  have  incorporated  a  number  of  the  former,  as  well  as  of 
dark-colored  flattened  blood-corpuscles.  The  accumulation  as  well  as 
the  general  importance  of  those  (new)  elements,  for  the  inflammatory 
process,  and  especially  the  stasis,  have  been  recognized  by  Addison  and 
others. 

The  momentous  question,  as  to  the  cause  of  the  said  formative  process 
of  blood  in  the  condition  of  stasis,  will  be  answered,  so  far  as  it  is  possi- 
ble, in  the  sequel. 

4.  Exudation. — The  thinning  and  permeability  of  the  walls  of  blood- 
vessels, produced  by  their  distension,  must  be  regarded  as  the  basis  of 
this  phenomenon,  even  in  the  instance  of  a  condensed  plasma ;  perhaps, 
additionally,  the  effort  at  equalization  betwixt  the  latter  and  any  thinner 
blood-serum  before  exuded. 

A  question  of  peculiar  interest  here  suggests  itself,  namely  :  wherefore 
in  the  inflammation  of  membranous  expansions  does  exudation  always 
take  place  upon  their  surface,  and  into  the  cavities  which  they  invest, 
whilst  the  effusion  beneath  is  limited  to  the  infiltration  of  the  implicated 
parenchyma,  or  of  the  subjacent  areolar  tissue — with,  for  the  most  part, 
an  inconsiderable  amount  of  plastic  serum  ?  This  applies  not  only  to 
mucous  and  serous  membranes,  but  even  to  other  more  delicate  hollow 
bodies — for  example,  follicles.  The  problem,  like  that  of  Johannes  Miil- 
ler,  as  to  natural  secretions  affecting  the  free  surfaces,  is  only  to  be  solved 
upon  the  ground  of  less  resistance  being  offered  in  this  direction.  The 
said  infiltration  of  parenchymata  and  of  contiguous  textures,  is  co-signi- 
ficant with  the  oedema  that  surrounds  patches  of  inflammation. 

To  an  indefinite  distance  beyond  the  range  of  true  inflammation,  and 
lessening  in  intensity  as  the  distance  increases,  congestion  takes  place, 
and  with  it  the  effusion  of  serum.  And  the  serum  becomes,  in  like  man- 


104  INFLAMMATION. 

ner,  poorer  in  plastic  substances  towards  its  periphery.  Such  is  inflam- 
matory oedema ;  oedema  encompassing  the  range  of  inflammation. 

The  accompaniments  of  pain,  redness,  heat,  swelling,  are  explicable  as 
follows : 

Pain  is  determined — 

1.  In  external  injuries,  as  wounds,  burns,  cauterization,  either  by  the 
immediate  action  of  the  cause  of  the  inflammation  upon  the  peripheral 
nerves,  or  else  by  reflection  from  the  central  organs.     In  no  instance  is 
it  determined  by  the  inflammation  itself. 

2.  By  the  pressure  and  tension  which  the  dilated  and  overladen  ves- 
sels, and  the  effused  fluid  exercise  upon  the  nerves,  true  inflammatory  pain. 

3.  Finally,  pain  of  a  certain  degree,  or  rather  of  particular  kinds,  is 
to  be  referred  to  augmented  temperature  in  an  inflamed  part.     In  the 
absence  of  increased  warmth,  which  characterizes  certain  inflammations, 
pain  is  generally  absent,  also. 

The  redness  is  a  consequence  of  the  overloading  of  the  dilated  capilla- 
ries with  blood-corpuscles ;  it  is  therefore  to  be  designated  as  the  redness 
of  injection.  A  new  creation  of  bloodvessels  does  not,  as  was  once  sup- 
posed, ever  accompany  the  inflammatory  process  itself,  and  cannot, 
therefore,  be  taken  into  account  here. 

The  redness  is  also,  in  some  measure,  due  to  the  blood  thrown  out 
during  the  stage  of  congestion  and  stasis. 

In  some  inflammations,  one  great  source  of  the  redness  is  the  drench- 
ing of  the  tissues  with  dissolved  blood-pigment, — redness  of  imbibition. 

In  form,  the  redness  of  injection  varies  in  different  textures,  according 
to  the  order  in  which  their  capillaries  are  disposed.  Take  for  example 
the  linear  redness  of  injection  in  inflamed  fibrous  structures.  In  the 
most  vascular  structures,  however,  the  naked  eye  is  no  longer  cognizant 
of  aught  but  a  uniform  red  tint. 

Lastly,  the  redness  is  subject  to  many  gradations  of  color,  being  deeper 
in  proportion  as  the  organ  is  vascular,  and  the  congestion  intense.  Much 
depends,  moreover,  upon  the  constitution  of  the  blood,  and  more  espe- 
cially of  its  red  pigment ;  take,  for  instance,  the  copper-redness  of  the 
syphilitic,  the  violet  hue  of  the  typhous  stasis.  The  elevated  .tempera- 
ture has  its  source  partly  in  the  formative  processes,  in  which  blood  in 
the  condition  of  stasis  becomes  engaged,  but  for  the  most  part  in  the  ex- 
citation produced  upon  the  sensitive  nerves. 

The  swelling  is  dependent — 

(a.)  Upon  dilatation  and  repletion  of  the  capillaries ; 

(6.)  More  especially  upon  exudation  of  blood-serum  and  plasma  ; 

((?.)  Upon  concurrent  hemorrhagic  effusion  (extravasation). 

The  two  latter  conditions  give  rise,  in  like  manner,  to  the  loose,  lace- 
rable  condition  of  inflamed  textures. 

After  this  description  of  the  inflammatory  process,  and  this  interpre- 
tation of  its  phenomena,  we  should  proceed  to  investigate  the  so-called 
issues  of  inflammation.  These,  however,  resolution  excepted,  cannot  be 
satisfactorily  considered  without  an  insight  into  the  various  products  of 
inflammation,  nor  these  products  themselves  be  rendered  intelligible  but 
by  a  knowledge  of  the  manifold  varieties  and  anomalies  of  the  process, 
and  of  its  relation  to  the  blood-crasis. 


VARIETIES     OF     INFLAMMATION.  105 


VARIETIES    OF   INFLAMMATION. 

Inflammation  is  characterized  by  much  variety  and  anomaly.  On  the 
one  side,  it  recedes  so  far  from  the  foregoing  description  of  the  process, 
that  it  has  been  attempted  to  distinguish  certain  forms  as  spurious  in- 
flammation. On  the  other  side,  its  gradations  into  mere  hypersemia 
and  a  preternatural  amount  of  plasma-exudation  (nutritive  irritation) 
are  so  imperceptible,  that  discrimination  becomes  a  matter  of  difficulty, 
the  greater,  perhaps,  that  such  processes  frequently  do  become  exalted 
into,  and  do  alternate  with,  inflammation. 

Every  hyperaemia  may  attain  the  point  of  inflammatory  stasis. 

(a.)  Active  hypersemia^  the  same  in  origin  with  inflammatory  conges- 
tion, is  developed  into  sthenic,  or  active,  inflammation. 

(b.)  Passive  hypercemia, — the  result  of  direct,  centrical  or  peripheral 
palsy  of  the  entire  nerve-apparatus  of  an  organ, — becomes  passive,  as- 
thenic  inflammation.  To  it  belong,  amongst  others,  all  hypostatic  in- 
flammations, occurring  in  dependent  parts  during  the  progress  of  ady- 
namiae  and  marasmi,  and  the  asthenic  inflammations  in  organs  paralyzed 
by  concussion,  complex  injuries,  or  by  direct  central  influence, — for  ex- 
ample, of  the  bladder,  in  paraplegia.  Many  of  them  have  a  humoral 
origin,  a  dyscrasial  disturbance  giving  rise  to  paralysis  either  central  or 
directly  peripheral.  The  hypersemia  and  stasis  are  characterized,  in 
the  absence  of  pain  and  increased  temperature,  by  very  dark  livid  red- 
ness, partly  of  injection,  but  for  the  most  part  of  imbibition.  Their  pro- 
ducts, conformably  with  the  humoral  elements,  are  poor  in  coagulable 
material,  discolored  by  adherent  blood-pigment,  spuriously  reddened,  sero- 
albuminous,  sero-purulent.  Frequently  the  stasis  becomes  absolute,  de- 
generating into  necrosis  of  the  blood  and  of  the  diseased  texture ;  in  one 
word,  into  gangrene. 

(c.)  Mechanical  hypercemia,  as  we  have  seen,  commonly  determines 
exudation  of  serum  [oedema],  and  this  not  alone  from  the  true  capilla- 
ries, but  also  from  the  larger  veins.  By  intense  mechanical  obstruction, 
the  hyperaemia  is  raised  to  a  stasis  marked  by  very  deep  redness,  great 
tumefaction,  numerous  lacerations  of  vessels,  and  hemorrhage.  It  de- 
posits the  usual  coagulable  products,  but  often  degenerates,  with  com- 
plete paralysis  of  the  organ  affected,  into  absolute  stasis  and  gangrene. 

The  course  of  inflammation  is  acute  or  chronic  ;  all  else  being  equal, 
sthenic,  and  traumatic  inflammations,  and  (amongst  those  due  to  internal 
causes)  such  as  result  from  a  fibrino-croupous  crasis,  are  marked  by  their 
acute  character.  Asthenic  inflammations,  on  the  other  side,  and  of 
these,  more  especially  the  ordinary  hypostatic,  incline  to  a  chronic  course. 
Chronic  inflammation  is  variously  modified. 

(a.)  Inflammation  may  tarry  unwontedly  long  at  any  one  of  its  stages. 
It  is  in  unison  with  the  causal  conditions  upon  which  hypostatic  inflam- 
mations depend,  that  their  stasis  should  be  abiding.  The  congestion  is, 
moreover,  often  only  very  gradually  brought  about. 

(5.)  There  are  inflammations  in  which  a  decided  stasis  is  most  proba- 
bly never  arrived  at ;  the  process  consisting  in  prolonged  congestion, 
with  a  slackening  of  the  circulation,  bordering  upon  stasis.  Arrested 
processes  of  this  kind  give  rise  to  exudations,  poor  in  coagulable  mate- 


106  VARIETIES    OF    INFLAMMATION. 

rials,  serous  in  kind,  and  prone  to  accumulate  either  by  slow  degrees  or 
by  sudden  impulses. 

(c.)  Chronic  inflammation  consists  in  a  linked  succession,  stage  for 
stage,  of  inflammations  more  or  less  acute.  Amongst  the  most  marked 
are  those  occurring  in  the  vascularized  products  of  an  antecedent  in- 
flammatory process,  more  particularly  in  the  pseudo-membranous  pro- 
ducts of  inflammation  upon  serous  membranes. 

(d.)  Inflammations  productive  of  pus  and  ichor,  whether  of  external 
or  internal  origin,  are,  for  the  most  part,  essentially  chronic  processes 
imitative  of  a  secretive  function. 

In  point  of  degree  and  extension,  inflammations  offer  the  greatest  pos- 
sible variety.  For  the  degree  of  intensity  of  the  inflammation,  the 
intensity  of  the  external  appearances,  especially  redness  and  tumefaction, 
together  with  the  quantity  and  quality  of  the  products,  affords  a  crite- 
rion. This,  however,  applies  exclusively  to  inflammations  due  to  local 
external  causes.  In  inflammations  kindled  out  of  an  internal  humoral 
element,  the  mildness  of  the  stasis  and  of  its  symptoms  is  often  strikingly 
disproportionate  to  the  quantity  and  character  of  its  products.  Even 
the  former  kind  is  subject  to  frequent  exceptions :  thus,  purulent  exuda- 
tion, which  is  commonly  regarded  as  the  product  of  a  very  intense  stasis, 
not  unfrequently  occurs  in  great  abundance  under  slight  symptoms. 

The  extent  of  an  inflammation,  th^t  is,  its  diffusion  over  one  or  more 
organs,  depends  both  upon  its  occasional  cause  and  upon  accessory  cir- 
cumstances. Inflammations  evoked  by  dyscrasial  agency,  very  com- 
monly assault  large  organs,  or  at  least  considerable  sections  thereof, 
very  frequently  several  like-named  or  kindred  organs,  at  once,  or  in 
rapid  succession, — for  example,  serous,  mucous,  follicular  formations. 

Inflammation  is  not  essentially  modified  by  anatomical  differences  of 
organs  and  tissues.  We  may  here,  however,  remark  that — 

(a.)  Organs  differ  greatly  in  the  pr oneness  to  inflammation  from  an 
internal  humoral  cause,  there  being  a  certain  relation  of  organs  to  special 
erases.  Frequently,  however,  peculiar  extraneous  impulses  concur  to 
localize  a  crasis  upon  a  particular  formation ;  take,  for  instance,  the 
localization  of*  the  puerperal  crasis  upon  the  peritoneum,  a  part  enlisted 
both  in  the  act  of  parturition  and  in  the  puerperal  uterine  process. 

(5.)  Vascularized  new  growths,  like  normal  textures,  may  become  the 
seat  of  inflammation,  luxuriate  in  growth,  and  increase  in  substance,  or 
else  decline  and  perish.  Sloughing  and  luxuriance  of  growth  are  here 
occasionally  concurrent  processes.  Tender,  budding  formations  are 
especially  apt  to  become  destroyed  by  inflammation,  at  the  same  time 
that  a  more  vigorous  germination  is  becoming  established  in  their  vicinity. 

The  distinctive  characters  of  regeneration  and  of  suppuration,  de- 
structive inflammation,  will  be  considered  under  the  head  of  Terminations 
or  Issues. 

Both  the  causes  and  the  products  of  inflammation  constitute  very  im- 
portant grounds  of  distinction,  and  a  rigid  discrimination  is  necessary 
between  inflammations  from  external,  and  inflammations  from  internal 
causes.  To  the  former  class  belong  not  alone  the  inflammations  locally 
engendered  by  direct  external  influences,  but  also  those  awakened  in 
remote  but  sympathetically  allied  formations,  through  the  mediation  of 


DYSCRASIAL    INFLAMMATION.  107 

the  nerves.  To  the  latter  class  belong  those  hypersemise  and  stases 
based  upon  a  greatly  overwrought  condition  of  the  nervous  centres,  be 
it  irritation  or  paralysis,  and  more  particularly  inflammations  arising  out 
of  a  pre-existent  dyscrasial  or  humoral  element. 

RELATION   OF  THE   INFLAMMATORY   PROCESS  TO   CRASIS. 

A  twofold  relation  exists  between  inflammation  and  an  anomalous 
crasis,  the  latter  being  either  a  mere  result  of  the  inflammatory  process 
and  secondary,  or  else  pre-existent  and  primary,  and  the  inflammation  a 
consecutive,  symptomatic  phenomenon, — the  localization  of  the  crasis. 

1.  The  undeniable  development  of  a  dyscrasial  condition  of  the  blood, 
as  the  sequel  to  mere  local  inflammation  produced  by  external  and,  it 
may  be,  traumatic  influences,  justifies  the  inference  that  inflammation  is 
in  itself  a  dyscrasial  process.  All  doubt  as  to  this  point  is,  however, 
overcome  if  we  consider — 

(a.)  The  qualitative  variations  in  the  products  of  a  local  inflammation ; 
and  still  more — 

(b.)  The  fact  that,  where  the  blood  is  in  the  condition  of  stasis,  the 
elements  of  the  exudation  are  found  preformed  within  the  vessels.  The 
character  of  the  products  is  thus  shown  to  be  mainly  dependent  upon 
inbred  transformations  of  the  stagnant  blood,  and  more  particularly  of 
its  plasma. 

Inflammatory  stasis  is  thus  shown  to  be  no  mere  passive  congestion ; 
effusion  to  be  no  mere  percolation  of  an  altered  plasma  simply  divorced 
from  the  blood-globules.  On  the  contrary,  both  are  shown  to  imply 
every  variety  of  conversion,  from  simple  exaltation  of  the  formative  pro- 
cess carried  on  in  normal  plasma,  to  the  generation  of  totally  heteroge- 
neous combinations  and  of  corresponding  form-elements.  For  the  same 
reason  the  plasma  effused,  and  the  fibrinous  matter  thrown  out  as  the 
result  of  inflammatory  stasis,  differ  from  mere  extravasated  plasma,  or 
extravasated  fibrin.  The  same  arguments,  in  fine,  serve  for  the  solution 
of  the  question :  in  what  wise  does  an  anomalous  constitution  of  the 
entire  blood-mass  result  from  local  inflammation  ? 

Consecutive  dyscrasy,  as  infection  of  the  blood,  is  brought  about — 

(a.)  Through  direct  readmission  of  effused  matter  into  the  circulation 
by  endosmosis,  or  through  the  indirect  way  of  resorption  through  lym- 
phatics ; 

(b.)  Through  a  more  copious  reception  of  the  products  of  inflamma- 
tion into  bloodvessels  laid  open  by  external  injury,  or  by  ulceration  and 
necrosis ; 

(c.)  And  (besides  these  commonly-taught  channels)  through  the  ebbing 
back  to  the  roots  of  the  veins  of  the  altered  plasma,  issuing  from  blood- 
vessels involved  in  the  process  of  inflammation. 

This  last  mode  of  infection  is  decidedly  the  most  common.  It  is, 
indeed,  the  only  one  possible  where  endosmosis  and  resorption  of  the 
substances  effused  are,  owing  to  the  density  of  the  latter  surpassing  that 
of  the  lymph  or  of  the  blood,  excluded.  It  resembles,  on  a  small  scale, 
that  infection  of  the  blood  due  to  inflammatory  products  directly  thrown 


108  DYSCRASIAL    INFLAMMATION. 

out  into  the  cavities  and  canals  of  the  circulation  from  their  internal 
membranes. 

The  interest  and  the  practical  importance  of  the  subject  warrant  us, 
whilst  referring  to  the  chapter  on  blood  diseases  and  on  pyaemia,  in 
remarking  here  that, — if  we  except  cases  engendered  by  very  heteroge- 
neous substances,  the  result  of  decomposition  within  or  without  the 
vessels, — infection  stands  in  direct  relation  to  the  magnitude  and  number 
of  the  inflamed  parts,  and,  as  a  consequence,  to  the  amount  of  inflam- 
matory products  taken  up  into  the  blood.  In  opposition  to  a  fermenta- 
tion theory,  we  may  affirm  that  a  minimum  of  inflammatory  product  does 
not  suffice  to  determine  a  perceptible  alteration  of  its  admixture,  very 
small  quantities  merging  in  the  normal  processes  of  the  circulating  mass. 
The  most  pregnant  source  of  infection  is  the  inflammation  of  the  internal 
membrane  of  bloodvessels. 

The  character  of  the  infection  and  of  the  consequent  crasis  corre- 
sponds with  that  of  the  products  of  the  inflammatory  stasis. 

Consummated  infection  of  the  blood-mass  bears  towards  every  inflam- 
mation which  it  may  subsequently  call  forth,  the  relation  of  a  primitive 
crasis  localized  in  congenial  inflammation. 

2.  In  every  crasis,  hyperaemia  and  stasis  may  occur  accidentally. 
Here,  however,  we  are  more  particularly  concerned  with  inflammations 
resulting  from  a  special  crasis  as  their  internal  and  sole  cause.  To  this 
class  belong  a  multiplicity  of  anomalous  erases,  more  especially,  however, 
the  fibrin-crasis  and  pyaemia,  the  former  being  usually  comprised  under 
the  so-called  phlogistic  crasis.  Inflammations  dependent  upon  dyscrasial 
impulses  are  marked  by  their  preference  for  particular  organs,  and,  for 
the  most  part,  by  the  acuteness  of  their  career,  as  well  as  by  the  rapid 
formation  of  their  products. 

This  last  circumstance  is,  to  a  certain  extent,  practically  demonstra- 
ble with  respect  to  the  fibrin-erases  and  pyaemia.  In  these,  the  exami- 
nation of  the  blood  shows  that,  the  same  changes  occur  in  its  totality,  as 
in  any  portion  of  it  in  the  condition  of  stasis ;  that  both  the  plasma  and 
the  fibrin  are  constituted  identically  with  the  products  of  the  stasis. 
Herein  a  source  is  supplied  for  the  rapid  development  of  the  stasis,  and, 
consequently,  of  the  effusion.  In  the  stasis,  a  simple  increase  of  the 
processes  carried  on  in  the  totality  of  the  blood  suffices  to  furnish  forth, 
in  exquisite  form,  a  characteristic  exudation. 

Inflammation  of  humoral  origin  is  determined,  according  to  the  neuro- 
pathological  theory,  by  antagonistic  palsy  of  the  nerves  of  the  blood- 
vessels, brought  about,  at  the  periphery  or  at  the  centres,  by  the 
irritating  effect  of  the  dyscrasial  blood  upon  the  sensitive  nerves ;  or,  if 
passive,  by  direct  paralysis.  To  such  inflammations  unquestionably  be- 
long many  commonly  ascribed  to  an  external  cause ;  for  example, 
pneumoniae.  These  we  believe  to  be,  for  the  most  part,  the  localization 
of  a  crasis  modified  by  atmospherical  influences. 

The  relation  of  the  crasis  to  particular  domains  of  the  nervous  system, 
determines  the  localization  of  certain  erases  in  particular  organs,  almost 
as  a  definite  rule.  Still,  the  modifying  power  of  concurrent  external 
influences  is  not  to  be  lost  sight  of. 

Inflammation  arising  out  of  humoral  elements  manifests  itself  not 


EXUDATION.  109 

unfrequently  as  a  metastasis,  exhausting  the  crasis  and  resolving  itself 
into  a  local  evil. 

The  above  becomes  invested  with  greater  significance  when  applied  to 
the  exudatory  processes  upon  which  the  production  of  various  hetero- 
logous  formations  rests. 

EXUDATION. 

The  greatest  and  most  marked  differences  of  inflammation  are  mani- 
fested in  its  products.  In  inflammations  due  to  a  pre-existent  crasis, 
such  difference  is  intelligible  enough,  the  product  of  the  stasis  having  its 
germs,  in  part  at  least,  preformed  in  the  general  circulation.  It  is  less 
clear  with  respect  to  inflammations  devoid  of  a  pre-existent  crasis. 
Mere  local  inflammation,  however,  independent  of  any  dyscrasial  mate- 
rials, will  yield  products  presenting  a  repetition  of  many,  if  not  of  all, 
the  characters  which  mark  the  products  of  dyscrasial  inflammation,  such 
as  simple  (plastic)  fibrinous  exudation,  fibrino-croupous  (pyin-holding) 
exudation,  pus,  ichor.  Here  the  question  is :  wherein  are  the  different 
characters  founded  ?  how  elicited  by  stasis  out  of  normal  matter  ?  Their 
ultimate  source  can  be  no  other  than  the  stasis  itself,  of  which  it  might  be 
predicated — 

(a.)  As  stasis  it  promotes,  and,  within  its  range,  condenses  upon  in- 
considerable elementary  materials,  the  changes  and  formative  processes 
which  take  place  in  the  general  circulation. 

(b.)  When  feeble  in  intensity  it  determines  mechanically  the  display 
of  thin,  serous,  sero-fibrinous,  sero-albuminous  substances,  poor  in  plastic 
materials. 

(c.)  Greater  intensity  and  duration  occasion  relatively,  through  the 
continued  afflux  of  oxygen  to  a  given  quantity  of  plasma  engaged  in 
stasis,  excessive  fibrin  formation,  and  ulterior  oxidation  of  the  fibrin. 
Hence  result  fibrinous  exudation,  and,  as  a  higher  degree  of  oxidation 
of  the  protein  (Mulder),  croupous  constitution  of  the  fibrin,  croupous 
exudates,  pus-  and  ichor-exudates. 

(d.)  Absolute  stasis,  deficiency  of  oxygen,  leads  to  necrosis  of  the 
blood  and  of  the  implicated  textures, — gangrene. 

The  exudate  is,  accordingly,  now  of  general,  now  of  local  import. 
Exudates,  when  formed,  suffer  various  changes  through  external  influ- 
ences, and  take  various  impressions  not  inherently  theirs ;  thus  not 
unfrequently  entering  upon  anomalous  modes  of  development.  Like 
blastemata,  they  do  not  exude  unalloyed;  croupous  fibrin  and  pus,  for 
example,  being  always  mingled  with  a  certain  amount  of  so-called  plastic 
fibrin  and  normal  plasma.  Nevertheless,  the  study  of  exudates  in  their 
utmost  simplicity  of  forms  is  indispensable. 

Exudates,  indeed,  both  in  their  primitive  condition,  and  in  the 
changes  which  they  undergo,  irrespectively  of  impressions  from  without, 
afford  an  insight  into  the  local  processes  occurring  in  blood  involved  in 
stasis,  as  also  into  the  processes  carried  on  in  the  general  circulation, 
that  is  to  say,  into  the  crasis  itself. 

The  most  instructive  of  all  exudates  are  those  occurring  upon  serous 
and  mucous  membranes,  upon  which  many,  if  not  most,  erases  are  wont 
to  localize. 


110  EXUDATION. 

The  doctrine  of  inflammatory  exudation  is,  in  many  points,  applicable 
to  the  products  of  other  processes  of  exudation,  nor  shall  we,  in  the 
sequel,  neglect  the  opportunity  of  generalizing  in  this  sense. 

Let  us  pass,  in  the  mean  time,  to  the  enumeration  of  exudates  as  esta- 
blished according  to  anatomical  research,  taking  at  the  same  time,  a 
general  survey  of  the  various  changes  which  they  undergo. 

1.  Fibrinous  exudation  comprises  several  varieties,  each  correspond- 
ing to  a  particular  constitution  of  the  fibrin  of  blood  involved  in  stasis, 
or  of  the  general  circulation.  They  are,  for  the  most  part,  not  pure, 
one  kind  being  always  alloyed  with  a  proportion,  however  minute,  of 
another  kind,  and  a  certain  amount  of  normally  constituted  fibrin  attach- 
ing to  all. 

(a.)  Simple  or  plastic  fibrinous  exudation. — A  grayish,  yellowish- 
gray,  or  if  containing  blood-corpuscles,  even  red,  reddish-gray  exudate 
which,  in  great  part,  speedily  solidifies,  into  bulky,  membranaceous, 
plug-like,  or  frame-like  coagula,  whilst  the  remainder,  where  the  propor- 
tion of  blood-serum  is  considerable,  coagulates  in  the  latter  into  flocculi, 
thus  parting  into  a  solid  and  a  fluid  constituent.  It  presents  itself,  on  a 
closer  inspection,  as  a  clodded,  fibrous,  diaphanous  blastema,  of  very 
tenacious  properties,  the  broken  surface  of  which  is  felt-like  and  studded 
with  nuclei  and  nucleated  cells.  It  answers  to  fibrin  2.  It  is  observed 
in  its  purest  form  in  wounds,  when  these  agglutinate  and  heal  by  the 
first  intention.  Besides  this,  it  occurs  upon  the  pleura,  in  areolar  tissue, 
in  muscles,  in  bones,  upon  the  endocardium  and  the  internal  bloodvessel 
membrane,  in  the  brain,  occasionally,  as  pneumonia,  in  the  parenchyma 
of  the  lung,  which  either  slowly  recovers  its  natural  state  through  ab- 
sorption, or  ends  in  induration  with  extinction  of  the  pulmonary  texture. 
Upon  serous  membranes  it  constitutes  the  peripherous  coagula  lining  the 
inner  surface  of  serous  sacs.  It  frequently  enters,  in  common  with  a 
certain  proportion  of  normally  constituted  fibrin,  into  the  composition  of 
other  exudates,  as  that  portion  of  them  upon  which  a  change  of  texture 
depends,  for  example,  into  the  croupous,  the  purulent,  &c. 

The  following  are  its  metamorphoses,  the  most  remarkable  amongst 
which  is  its  textural  conversion. 

(a.)  It  becomes  partially  or  wholly  reabsorbed ;  this  occurs  slowly, 
through  the  instrumentality  partly  of  the  serous  portion  of  the  exudation 
itself,  partly  of  a  supplementary  effusion  of  serum,  succeeding  to  the 
resolution  of  the  stasis.  These  humors  furnish  the  solvent — the  cor- 
roding media,  so  to  speak,  for  the  solidified  fibrin  effused,  having  incorpo- 
rated which,  layer  by  layer,  either  in  solution,  or  in  a  state  of  minute 
subdivision,  they  forthwith  become  reabsorbed.  In  like  manner,  the 
fibrinous  coagula  within  the  vascular  system ;  for  example,  vegetations, 
thrombi,  &c.,  are  progressively  taken  up  again  into  the  blood. 

(/?.)  It  wastes  and  hardens,  with  the  loss  of  its  fluid  part  and  with 
lessening  of  its  volume,  to  a  horny,  and  eventually,  perhaps,  to  an 
ossified  mass. 

(y.)  It  undergoes  a  change  of  texture,  commonly,  and  for  the  greater 
part,  consisting  in  an  ulterior  development  of  that  fibrillation  of  the 
blastema  which  ensues  upon  the  solidifying  of  the  exudate.  To  avoid 


EXUDATION .  Ill 

repetition,  we  refer  for  the  details  of  this  process  to  the  heads — New 
Growth  of  Areolar  Tissue,  and  Fibroid  Formations. 

In  rare  instances,  the  new  formation  of  bloodvessels  is  predominant 
therein,  more  especially  in  exudates  upon  the  arachnoid  membrane.  In 
the  vicinity  of  serous  membranes,  there  result  serous  layers,  a  new  serous 
sac ;  in  contiguity  with  bone,  bony  texture. 

The  time  requisite  for  these  transformations  is  scarcely  definable  in 
a  general  way.  Under  favorable  circumstances,  they  are  wont,  even  in 
voluminous  exudates,  to  attain  an  advanced  or  nearly  completed  state, 
within  the  space  of  six  weeks. 

The  constitution  of  the  exudate  corresponds,  as  before  stated,  with 
that  of  fibrin  2,  having  either  been  acquired  in  the  stasis  or  pre-existed 
as  a  blood  erase.  It  is  a  quantitative  anomaly  consisting  in  an  exagge- 
ration of  the  formative  processes  which  occur  in  normal  plasma, — and 
especially  in  the  locally  and  generally  increased  generation  of  a  fibrin 
(hyperinosis)  marked  by  its  coagulable  and  plastic  properties. 

(b.)  Croupous  exudation  has  several  varieties,  dependent  upon  a 
qualitative  impairment  of  the  fibrin.  It  is,  with  the  utmost  impropriety, 
confounded  with  the  former  and  its  kindred  erases.  It  is  marked  by  a 
high  degree  of  coagulability ;  by  a  yellow,  or  greenish-yellow  coloration ; 
by  its  opacity ;  by  its  inorganizable  nature  ;  by  its  early  tendency  to 
break  down,  to  liquefy ;  frequently  by  a  corrosive,  texture-softening 
power.  The  quantity  of  serum  simultaneously  thrown  out  is  relatively 
insignificant. 

The  croupous  process  of  exudation  and  its  product  are  further  dis- 
tinguished, 

1.  By  the  commonly  excessive,  exhausting,  quantity  of  the  exudate, 
and  its  extension  over  wide  ranges  of  organs  and  textures. 

2.  By  the  rapidity  with  which  the  effusion  is  brought  about,  where  the 
stasis  depends  upon  a  pre-existent  crasis. 

3.  By  the  often  slight  vascularity  of  the  diseased  texture ;  a  circum- 
stance due,  it  may  be,  to  the  blood-corpuscles  not  appearing  prominently 
in  the  opaque,  over  vigorous  plasma,  or  else  to  the  exudate,  by  its  ex- 
cessive quantity,  soon  leaving  the  bloodvessels  exsanguine  and  collapsed. 

4.  By  less  adhesiveness. 

5.  By  considerable  fattiness  of  the  exudate. 

The  principal  metamorphosis  of  the  croupous  exudate  is  the  aforesaid 
breaking  down,  and  liquefying  to  a  fluid  more  or  less  analogous  to  pus, 
which  constitutes  the  so-called  liquid,  purulent  exudate. 

This  metamorphosis  first  of  all  affects  the  solidified  blastema  interven- 
ing between  certain  form-elements  of  the  exudate ;  only  in  an  adhe- 
rent portion  of  organizable  fibrin  does  the  latter  undergo  a  change  of 
texture — namely,  to  areolar  tissue.  When  liquefied,  it  may  be  wholly 
reabsorbed,  or  may  leave  a  residue  in  the  shape  of  a  fatty,  curd-like, 
cretaceous  pap,  or,  lastly,  of  a  glutinous  fluid,  abounding  in  free  fat  and 
in  salts  of  lime  (in  elementary  granules,  granulated  cells,  cholesterine 
crystals),  which  speedily  thickens  into  a  cretaceous  concrement. 

(a.)  Croupous  Exudation,  an  abundant,  proportionately  to  its  con- 
tents in  blood-globules  or  in  blood-pigment,  more  or  less  red  (red  hepati- 
zation  of  lung),  or  grayish-yellow  mingling  with  green,  opaque  exudate, 


112  EXUDATION. 

consisting  of  a  sod-like,  fibro-laminated,  or  striated  membranous  base- 
ment, a  large  proportion  of  dotted  substance,  nucleated  formations,  dull 
granulated  nuclei  and  nucleated  cells.  The  nuclei  are  not  influenced  by 
acetic  acid,  beyond  some  little  shrivelling,  together  with  a  sharpening 
of  their  contours.  This  answers  to  the  constitution  of  fibrin  3.  It  lique- 
fies first  in  its  basement  mass,  with  change  of  texture  of  any  adherent 
portion  of  organizable  fibrin,  to  a  pus-like  fluid. 

(/5.)  Croupous  Exudation.  The  above-mentioned  characters,  espe- 
cially the  opacity  and  the  greenish  coloration,  are  here  more  strongly 
developed.  It  consists,  together  with  an  amorphous  blastema,  of  nucleus 
and  cell-formations,  more  or  less  akin  to  pus-nuclei  and  pus-cells,  and  of  a 
predominating  quantity  of  granulated  substance.  It  adheres  loosely  to 
the  exudation-surfaces  and  deliquesces  rapidly.  It  answers  to  fibrin  4. 

These  exudates  occur  most  of  all  upon  membranous  expansions,  upon 
mucous  membranes  (as  the  well-known  croup),  upon  serous  and  synovial 
membranes,  and  in  the  substance  of  the  lung.  Again,  they  occur  in 
areolar  tissue,  in  the  pia  mater,  in  the  convexity  of  the  cerebral  hemi- 
spheres, upon  the  endocardium  and  the  internal  bloodvessel  membranes, 
in  parenchymata,  and  upon  the  surface  of  both  internal  and  external 
sores.  Almost  all  the  pneumonias,  except  those  ending  in  slow  resorption 
or  induration  of  their  product,  belong  to  this  class,  and  pre-eminently 
those  in  which  the  lung  becomes  enormously  distended  with  a  very  copi- 
ous, rapidly  deliquescent  yellow  effusion,  the  stage  of  red  hepatization 
being,  in  Hodgkin's  opinion,  here  altogether  wanting. 

As  the  exudates  break  down,  they  exert,  especially  after  long-con- 
tinued contact,  the  aforesaid  corrosive  liquefying  influence  upon  their 
substrata,  occasioning  ulcerous  loss  of  substance,  pulmonary  abscess, 
destruction  of  serous  membranes,  ulcerous  perforation  of  the  thoracic, 
the  abdominal,  parietes,  &c. 

(f.)  Croupous  Exudation. — Aphthous  Exudation,  a  yellow,  green- 
ish-yellow, dingy-grayish,  opaque  product,  wont,  upon  surfaces,  to 
solidify  into  tough  membranes,  and  then  melt  down,  reducing  the  impli- 
cated textures  to  the  same  condition.  This  said  product  consists  some- 
times in  simple  destruction  of  the  textures,  sometimes  in  a  blending  into 
a  variously  discolored,  fetid,  ichorous  pulp,  or  into  a  tenacious,  greasy 
slough,  which  tears  like  tinder. 

These  exudates  affect,  with  especial  frequency,  the  mucous  membranes, 
particularly  those  of  the  alimentary  canal,  of  the  urine  bladder,  of  the 
female  sexual  organs,  with  their  follicles ;  secondly,  external  sores  and 
ulcers ;  thirdly,  the  common  integuments.  Under  this  head  belong 
thrush  or  aphthae,  diphtheritis,  exudates  upon  the  intestinal  mucous 
membrane  of  the  intestines,  and  of  the  colon  in  particular  as  represent- 
ing one  form  of  dysentery,  and  of  the  uterus  after  childbirth  ;  corroding 
exudates  upon  external  and  internal  wounded  and  ulcerated  surfaces,  for 
example,  on  the  base  of  the  typhous  ulcer,  white  gangrene  of  the  com- 
mon integuments,  hospital  gangrene. 

Croupous  exudation  is  occasionally  the  product  of  an  intense  inflam- 
matory stasis,  unconnected  with  any  pre-existent  crasis.  It  is,  however, 
much  more  frequently  the  product  of  a  stasis  in  which  the  croupous 
crasis  has  suddenly  become  localized. 

(c.)  A  special  form  of  fibrinous  exudation  is  the  tuberculous — the  true 


EXUDATION.  113 

fibrino-tuberculous.  It  is  a  repetition  both  of  simple,  and,  when  en- 
gendered by  inflammation,  of  croupous  exudation.  It  is  characterized  by 
a  proneness  to  tarry  long  in  its  primitive,  crude  state,  and  eventually 
to  soften  down. 

It  exudes  almost,  if  not  wholly,  pure,  or  else  blended  with  a  certain 
proportion  of  organizable  fibrin.  In  the  former  case  it  represents  a 
homogeneous  gray,  or  yellow,  curd-like,  brittle,  fissured  mass  ;  upon 
serous  membranes,  a  similar  uniform  layer,  of  uneven  stellate  surface. 
In  the  second  case,  the  tuberculous  matter  is  imbedded  in  the  shape  of 
more  or  less  crowded  tubera  clusters,  or  larger  masses,  within  the  other 
portion  of  the  effusion,  which  has  attained  to  various  grades  of  textural 
development.  In  the  last-mentioned  case,  more  especially,  tuberculous 
exudation  is,  upon  serous  membranes,  always  characterized  by  clustering 
of  the  granules. 

Tuberculo-croupous  exudation  affects  serous  and  mucous  membranes, 
evincing  a  preference  for  those  of  the  bronchial,  of  the  alimentary,  canal, 
of  the  uterus,  and  of  the  cavity  of  the  tympanum.  It  invades  the  paren- 
chyma of  organs  at  all  points,  but  most  of  all  that  of  the  lungs,  as  infil- 
trated tuberculous  pneumonia  of  the  lobar,  or  still  more  commonly  the 
lobular  form,  the  substance  of  lymphatic  glands  ;  lastly,  the  interior  of 
follicles,  and  particularly  the  Peyerian  capsules. 

There  are  cases  in  which  it  may  be  but  the  local  produce  of  a  stasis. 
More  commonly,  however,  this  stasis  is  itself  a  localization  of  the  tubercle 
crasis,  and  the  tuberculous  exudate  the  prodcct  of  general  dyscrasial 
processes. 

2.  Albuminous  exudation  occurs  united  to  a  proportion  of  fibrin  as 
a  fibrino-albuminous ;  or  as  a  mere  albuminous  ;  or  again,  mingled  with 
a  certain  proportion  of  serum,  as  a  sero-albummous  exudate. 

Albuminous  exudates  are  marked  by  their  fluidity,  by  their  tenacious, 
ropy  consistence,  often  by  their  abundance.  They  are  colorless  and  re- 
semble a  thick  synovia ;  or  milk-white  and  opaque ;  or  again  blended 
with  croupous  fibrin  and  of  a  yellowish-white.  Their  turbidness,  and 
also  their  thick  porridge-like  nature,  are  due  to  their  quota  of  form- 
elements  (elementary  granules,  nuclei,  cells),  to  their  proportion  of  fat, 
and  to  fatty  conversion  (granule-cells) ;  or  again,  they  are  due  to  an  act 
of  coagulation,  the  albumen  assuming,  by  virtue  of  a  chemical  conversion 
of  the  entire  exudate,  the  coagulate  form.  Coagula  of  this  kind  are 
for  the  most  part  soft,  flocculent,  forming,  upon  serous  membranes, 
velvety  deposits, — not  unfrequently  as  the  inner  coating  to  a  periphe- 
rous  fibrinous  coagulation. 

The  form-elements,  present  in  various  amount  in  the  albuminous  exu- 
date, are  identical  with  those  found  in  the  fibrinous  exudate,  nucleus 
and  cell  exhibiting  themselves  in  multiform  variety,  ending  with  the 
perfect  pus-cell. 

It  is  very  rare  for  albuminous  exudates  to  assume  at  once — that  is, 
immediately  on  becoming  effused,  the  solid  form. 

The  changes  which  albuminous  exudates  undergo,  vary  with  the  cha- 
racter of  the  albumen.  In  the  one  case,  they  enter  into  a  progressive 
transformation  of  texture,  which  in  fluid  albumen  obeys — in  solidified 

VOL.  I.  8 


114  EXUDATION. 

albumen  evades — the  laws  of  the  cell  theory,  thus  determining  hyper- 
trophy of  the  areolar  tissue,  and  induration  and  extinction  of  the  paren- 
chyma, for  example,  in  the  lungs.  In  dyscrasial  constitution  of  the  albu- 
men, on  the  other  hand,  they  have  a  decided  tendency  to  liquefaction,  to 
fatty  conversion,  whereby  they  become  either  fitted  for  resorption,  or 
endowed  with  a  corrosive  power. 

Their  appearance  is  for  the  most  part  connected  with  a  crasis,  involv- 
ing either  a  simple  predominance  of  albumen  (deficiency  of  fibrin)  in 
the  blood,  or  concurrently  a  dyscrasial  condition  of  the  former.  To  the 
first  description  belongs,  for  instance,  the  venous  diathesis  (Venositat), 
the  concomitant  of  heart  disease,  of  infancy,  and  of  extreme  age,  of 
atrophy,  of  defibrination.  The  products  are  represented  by  colorless, 
adhesive,  pasty  exudates,  poor  in  form-elements,  and,  owing  to  the  often 
low  intensity  of  the  stasis,  largely  diluted  with  serum ; — sero-albuminous. 
To  the  second  description  belong  the  erases  which  attach  to  cutaneous 
affections,  to  typhus  and  the  like,  with  their  dull  whitish  effusion ;  and, 
again,  the  anomalous  quality  of  albumen  pertaining  to  the  fibrino-croup- 
ous  crasis,  to  pyaemia  and  the  like,  with  their  pus-like  effusion.  The 
stases  are  often  of  the  asthenic  or  hypostatic  kind,  and  run  a  protracted 
course. 

3.   The  serous,  dropsical  exudate. 

Serous  effusions  are,  generally  speaking,  either  merely  serous  (blood- 
serum)  ;  or  again  from  their  containing  a  larger  proportion  of  albumen, 
albumino-serous ;  or,  lastly,  owing  to  an  admixture  of  fibrin,  fibrino- 
serous.  This  gives  rise  to  several  important  distinctions  in  their  physical 
bearings.  The  mere  serous  effusion  is  a  thin,  watery,  limpid,  colorless, 
or  pale  yellowish,  now  and  then  reddish-yellow  fluid,  salt  to  the  taste, 
and  containing  little,  if  any,  albumen.  A  large  proportion  of  albumen 
renders  it  tenacious,  like  a  thin  synovia.  An  admixture  of  fibrin  mani- 
fests itself  upon  serous  membranes  as  a  peripherous  coagulum  of  incon- 
siderable thickness,  as  a  villous  deposit,  as  a  filamentous,  wide-meshed, 
network  or  finely  membraned  honeycomb,  or  as  a  flocculent  cloud  within 
the  serous  fluid.  Or  again,  it  may,  in  the  shape  of  the  so-called  spurious 
fibrin,  which  solidifies  tardily,  perhaps  only  after  cooling  and  coming  in 
contact  with  the  air,  appear  in  the  effused  serum  as  soft,  jelly-like,  trans- 
parent, coagulate  pellets,  which  are  often  found  lodged  within  the  afore- 
said true  fibrinous  network,  or  honeycombed  structure.  Fibrino-serous 
effusion  may  be  said  to  be  invariably  the  product  of  an  inflammatory 
stasis.  It  is  simply  fibrin-exudate,  with  a  notable  preponderance  of 
serum.  It  might  well  be  denominated  fibrinated  dropsy. 

Albumino-serous  effusion  is  sometimes,  like  that  previously  described, 
the  product  of  a  not  very  intense,  often  of  a  protracted,  stasis  or  simple 
congestion.  As  an  example,  may  be  cited  the  (inflammatory)  oedema, 
encompassing  the  range  of  an  inflammation.  It  occurs  more  commonly 
independent  of  the  latter,  in  the  albumino-serous  crasis,  as  general 
oedema. 

Mere  serous  effusion  is  the  result  of  an  excess  of  serum  in  the  blood — 
the  serous  crasis ;  or  else  it  is  the  product  of  acute  and  more  frequently 
of  chronic  hyperaemia.  In  the  latter  case,  the  effusion  seems  to  origi- 
nate less  from  the  capillaries  than  from  the  small  thin-membraned  veins. 


PUS,   ICHOR.  115 

It  represents  genuine  dropsy,  and  does  not  at  all  imply  a  foregone 
inflammatory  stasis. 

Serous  effusion,  as  such,  is  not  organizable.  Albumen  and  fibrin, 
however,  when  blended  with  it  in  sufficient  quantity,  are  susceptible  of 
a  somewhat  tardy,  structural  change.  It  relaxes  and  tumefies  the 
textures  on  becoming  imbibed,  destroys  their  contractility,  and  by  long- 
continued  contact  exerts,  more  especially  upon  the  muscular  fibres,  a 
remarkable  power-bereaving  influence. 

4.  Purulent  and  icJiorous  effusion.  These  range  immediately  with 
fibrinous  and  albuminous  exudation,  as  also  with  their  fibrino-serous, 
albumino-serous  combinations.  Purulent  effusion  seems,  however,  to  be 
more  especially  akin  to  the  fibrino-croupous  exudate. 

The  importance  of  these  products  renders  it  desirable  to  discuss  them 
at  greater  length. 

PUS,  ICHOR. 

No  product  of  disease  has,  perhaps,  been  the  subject  of  such  zealous 
research  as  pus  and  ichor,  and  yet  nowhere  has  a  greater  number  of 
shortcomings  been  overlooked  or  glossed  over  than  here.  These  we 
may  be  incompetent  to  remedy ;  we  may,  however,  render  some  slight 
service  to  pathology  if  we  can  succeed  in  simply  directing  attention  to 
them. 

There  are  so  many  kinds  of  purulent-looking  fluids,  and  there  is  so 
great  an  affinity  of  these  fluids  amongst  each  other,  that,  for  the  sake  of 
discrimination,  it  is  indispensable  to  establish  one  standard  form  of  pus. 
Such  a  standard  form  is  furnished  in  the  pus  of  granulating,  healing 
wounds,  as  well  as  in  that  of  certain  abscesses. 

This  normal  pus  is  a  homogeneous,  cream-like,  fatty,  glutinous  fluid, 
of  a  yellowish  color,  of  a  flat,  sweetish  smell  and  taste,  of  a  specific 
gravity  of  from  1030  to  1333  (Vogel),  and  when  recent,  of  alkaline 
reaction. 

It  consists  essentially  of  pus-serum,  with  certain  form-elements,  these 
being,  besides  molecular  granules  (elementary  granules),  the  pus-nucleus, 
and  the  pus-cell.  To  these  is  to  be  added  the  pus-placenta,  of  which 
more  hereafter. 

The  pus-cell  is  a  spherical  or  oval — now  smooth  and  even,  transpa- 
rent, thin  membraned — now  granulated  and  opaque,  nucleated  cell, 
which,  under  a  magnifying  power  of  400  diameters,  appears  colorless, 
or  faintly  yellow,  and  measures  from  T£Q  to  gVh  of  a  millimetre  in 
diameter. 

Its  granulated  nucleus,  firmly  attached  to  the  cell-wall,  is,  in  the 
translucent  cell,  visible  without  the  aid  of  artificial  expedients.  In  the 
granulated  cell,  on  the  contrary,  it  is  rendered  indistinct,  if  not  totally 
obscured,  by  the  contents  of  the  cell,  but  is  readily  discernible  on  the 
application  of  acetic  acid.  It  generally  occupies  from  one-half  to  two- 
thirds  of  the  cell's  cavity,  and  in  rare  instances  almost  fills  it  up. 
Generally  speaking,  it  is  single  ;  not  unfrequently,  however,  it  is  mani- 
festly composed  of  from  two  to  five  smaller  corpuscles.  Normal  pus 
only  rarely  contains  larger  cells,  with  two,  three,  or  four  nuclei.  Under 


116  PUS,    ICHOR. 

the  action  of  acetic  acid,  each  pus-nucleus  being  brought  out  with  sharper 
contours,  as  a  spherical  (according  to  Vogel,  cupped)  body,  presents  the 
well-known  characteristic  phenomenon  of  indentation  and  eventual  split- 
ting. In  other  words,  the  nucleus,  after  passing  through  sundry  modi- 
fications of  shape,  down  to  that  of  a  trefoil,  finally  breaks  up  into  two, 
three,  or  four  sharply-defined  corpuscles,  no  further  soluble  in  acetic 
acid. 

Besides  the  cell-inclosed  nuclei  there  are  present  free  nuclei.  These 
are  in  like  manner  either  single  (perfected),  or  made  up  of  from  two  to 
five  corpuscles,  and  they  exhibit  the  same  phenomenon  of  indentation 
and  splitting,  when  treated  with  acetic  acid. 

The  molecular  granules  are  present  in  various  numbers,  some  scat- 
tered, others  grouped  together. 

The  contents  of  the  cells  are  in  some  cases  -limpid,  in  others,  owing 
to  very  minute  granulations,  nebulous.  It  is  very  common  to  find  one 
compact  group  of  pus-cells  presenting  every  known  gradation  in  the 
quality  of  their  contents. 

The  development  of  the  pus-cell  is  easily  demonstrable,  falsifying  the 
assertion  that  the  nuclei  are  artificially  produced  by  chemical  agency. 
For  the  most  part  from  two  to  five  of  the  larger  molecules  associate 
themselves  into  a  group,  and  constitute,  thus  aggregated,  an  imperfect 
nucleus.  By  and  by  they  coalesce,  arid  present  a  simple,  finished  nu- 
cleus— a  fabric  reducible,  by  the  agency  of  acetic  acid,  to  the  very  same 
elements. 

The  nucleus  now  becomes  surrounded,  often  immediately,  with  a  cell 
wall,  so  closely  fitted  at  first,  as  to  require  the  endosmotic  agency  of 
water,  or  dilute  acetic  acid  to  disconnect  it,  and  render  it  cognizable. 
Many  nuclei,  however,  become  previously  endued  with  a  delicate  nebu- 
lous deposit,  which  by  and  by  puts  on  a  circumscribing  cell-envelope, 
and  assumes  the  contour  of  the  cell. 

These  formations  are,  to  a  greater  or  smaller  extent,  always  dis- 
cernible in  genuine  pus,  in  the  progress  of  germination. 

Cells  devoid  of  nuclei, — clear,  transparent  cells,  which  have  to  create 
a  nucleus  out  of  their  own  materials,  are  rare. 

The  phenomena  of  endosmosis  and  exosmosis  bring  out  the  pus-glo- 
bules with  great  clearness. 

The  chemical  relations  of  the  pus-cell  are  not  without  their  weight  in 
reference  to  its  constitution,  and  to  its  recognition. 

Dilute  acids,  for  example,  dilute  hydrochloric,  oxalic,  tartaric,  but 
especially  acetic  acids,  have  the  effects  of  tumefying,  loosening,  attenua^ 
ting,  bursting,  without  entirely  dissolving  the  pus-cells,  whilst  upon  the 
nuclei  they  produce  the  above-mentioned  appearance,  first,  of  greater 
distinctness  of  outline,  then  of  indentation,  and  lastly,  of  disruption. 

Caustic  alkalies  and  their  carbonates  convert  the  pus-cells  into  a 
jelly-like,  granulated  substance. 

Thin  solutions  of  certain  saline  substances,  as  for  instance,  of  chloride 
of  sodium,  hydrochlorate  of  ammonia,  nitrate  of  potash,  iodide  of  potas- 
sium, with  many  others,  cause  first  the  disappearance  of  the  sheaths, 
and  secondly,  the  swelling  up  of  the  nuclei  into  a  shapeless  grume. 

A  solution  of  borax  acts  like  the  alkalies,  only  less  rapidly.     Metallic 


PUS,     ICHOR.  117 

salts,  alcohol,  tannic  acid,  &c.,  which  coagulate  fluid  albumen,  render 
the  pus-globules  shrunken,  nebulous,  and  opaque. 

In  the  blood,  in  urine,  in  mucus,  and  in  saliva,  the  pus-cells  are  pre- 
served unchanged  ;  bile,  on  the  contrary,  occasions  a  disappearance  of 
the  sheaths,  and  a  bloated  aspect  of  the  nuclei. 

From  these  facts,  and  from  further  experiments  in  the  same  direction, 
Lehmann  and  Messerschmidt  draw  the  following  conclusions : 

1.  The  sheath  of  pus-cells,  turgescent  in  acids,  soluble  in  solutions  of 
caustic  alkalies,  and  of  their  saline  conjunctions,  is  identical  with  a  pro- 
tein-compound which  may  be  artificially  produced  out  of  albumen,  depo- 
sited by  water,  and  redissolved  by  alkaline  salts,  and  acetic  acid — a 
modified  albumen,  poor  in  salts,  constituting  a  transition  stage  to  fibrin 
— fibrin  a. 

2.  The  nucleus,  insoluble  in  acetic  acid,  soluble  in  solutions  of  alkalies, 
turgescent  in  solutions  of  salts,  a  protein-compound  similar  to  the  venous 
fibrin,  turgescent  in  salines — fibrin  b. 

3.  The  third  substance,  namely,  the  molecules  accompanying  the  pus- 
cells,  forming  part  of  the  contents  of  the  opaque  granulated  cells,  and 
even   exhibited  in  the  nuclei  (the  nucleus-corpuscles  of  Lehmann  and 
Messerschmidt),  are  uninfluenced  by  alkalies  or  borax,  and  are  regarded 
by  Lehmann  and  Messerschmidt,  as  a  substance  analogous  to  the  essential 
constituent  of  horny  texture.     They,  however,  partly  consist,  as  Vogel 
rightly  maintains,  of  fat. 

Besides  these  elements,  pus  not  unfrequently  contains  cholesterine- 
crystals,  crystals  of  ammonio-phosphate  of  magnesia,  animalcules,  &c. 

Like  Henle,  we  have  been  unable  to  satisfy  ourselves  of  the  above- 
mentioned  effect  of  alkaline  salts  or  of  borax  solution.  In  the  changes 
wrought  by  the  application  of  thin  solutions,  we  recognize  the  pheno- 
mena of  endosmosis  down  to  rupture  of  the  sheath  of  the  pus-cell ;  in 
the  changes  wrought  by  the  application  of  saturated  solutions,  a  shrivel- 
ling thereof. 

The  pus-serum  in  which,  when  at  rest,  the  pus-cells  gravitate,  has  the 
composition  of  blood-serum,  with  some  difference,  however,  in  the  rela- 
tive proportions  of  its  constituents ;  fat,  for  example,  predominating. 
With  respect  to  pyin,  to  which  we  shall  afterwards  have  to  recur,  our 
belief  is  that  it  is  not  a  constituent  of  normal  pus  at  all. 

Pure  pus  we  believe  to  be  an  albuminous  exudate,  out  of  which,  like 
other  elementary  bodies,  the  pus-cell  becomes  developed  by  virtue  of  a 
specific  conversion.  This  process,  the  so-called  development  of  pus  out 
of  fluid  blastema,  occurs  upon  surfaces — upon  mucous  membranes,  upon 
the  external  skin,  upon  open  wounds,  in  abscesses.  This  pus  exudate, 
however,  enters  frequently  into  combination  with  fibrinous  exudates  of 
different  kinds. 

Of  these,  we  could  first  mention  the  combination  with  the  fibrino-croup- 
ous  exudate,  because  this  furnishes  the  base  of  the  so-called  develop- 
ment of  pus  out  of  solid  blastema.  Whether,  or  how  far,  we  participate 
in  this  view,  will  appear  in  the  sequel. 

Both  upon  surfaces  and  within  parenchymata,  a  solidifying  fibrinous 
blastema  is  frequently  thrown  out.  A  careful  inspection  will  show,  im- 
bedded in  the  solid  basement,  as  also  floating  in  the  sero-albuminous 


118  PUS,     ICHOR. 

fluid,  molecular  granules  and  genuine  pus-nuclei  and  pus-cells.  Together 
with  these  are  always  found  a  few  nucleus  and  cell-forms,  which  vary  in 
their  relations,  more  especially  to  acetic  acid.  The  solid  basement  mani- 
fests itself  as  croupous  fibrin,  which  liquefies,  incorporates  the  aforesaid 
elements,  and  is  distinguished  by  its  great  abundance  of  the  most  minute 
molecules.  This  combination  of  pus  with  fibrino-croupous  exudate,  con- 
stitutes the  so-called  solid  pus,  or  the  pus-plug,  and  is  that  upon  which 
the  breaking  down,  the  softening,  of  inflammatory  induration,  abscess, 
and  the  like  depend.  The  pus-cell  is  always  developed  out  of  the  sero- 
albuminous  moisture  pertaining  to  the  fibrin-exudate,  never  out  of  or  at 
the  expense  of  the  latter  itself,  the  liquefaction  of  which  implies  a  meta- 
morphosis. This  pus,  in  virtue  of  its  constituent,  croupous  fibrin,  con- 
tains pyin. 

Another  combination  of  the  pus-exudate,  is  that  with  plastic  fibrin 
exudate.  This  frequently,  but  not  invariably,  furnishes  in  pus  the  basis 
of  new  solid  textures,  of  regeneration,  of  the  cicatrix.  The  fibrin-exu- 
date determines  the  pus-placenta. 

Pus  may,  without  impairment  of  its  primitive  character,  present  vari- 
ous anomalies,  for  example  : 

(a.)  Watery  pus ;  the  pus-cells  having  become  bloated  in  the  preternatu- 
rally  thin  medium. 

(b.)  Preternaturally  saturated  pus-serum,  as  containing  more  saline 
and  albuminous  matter.  The  pus-cells  appear  less  turgescent,  smaller, 
shrivelled,  denticulated. 

(c.)  Pus  which  has  become  acid  exhibits  the  nuclei  more  distinctly, 
more  sharply  defined,  and,  it  may  be,  in  a  slight  measure  ruptured,  within 
a  transparent  membranous  sheath. 

(d.)  Various  admixtures,  as  blood,  mucus,  epithelial,  and  other  textu- 
ral  debris.  It  is  to  be  remarked,  however,  that,  by  certain  admixtures, 
for  instance,  of  faecal  matter,  of  decomposed  urine,  and  again  by  its  acid 
conversion,  pus  may  become  transformed  into  a  corrosive  fluid,  and  its 
secreting  texture  goaded  into  the  production  of  ichor. 

The  nearest  approach  to  pus  is  found  in  broken-down  fibrino-croupous 
exudates.  It  has  been  seen  that  these  frequently  enter  into  a  combina- 
tion with  true  pus-effusion,  and  the  liquefaction  of  the  fibrino-croupous 
elements  in  pus-effusion  constitutes  what  is  termed  the  development  of 
pus  out  of  a  solid  blastema.  Broken-down,  pus-like,  fibrino-croupous  exu- 
date is  always  marked  by  its  fluid  parts  holding  in  suspension  a  large 
proportion  of  the  most  delicate  nebulous  molecules,  and  is  distinguished 
from  pus  by  the  relations  of  the  coexistent  nuclei  and  cells.  These  exu- 
dation elements,  namely,  manifest,  as  we  have  stated,  on  the  one  hand, 
an  insensibility  towards  acetic  acid,  under  the  influence  of  which,  by  an 
evident  condensation  and  shrinking,  the  cell-walls  and  contours  of  the 
nuclei  are  brought  more  distinctly  into  relief;  or  it  may  be  that  the 
cell-walls  and  cell-contents  are  rendered  clearer,  whilst  the  nucleus  be- 
comes condensed  and  more  sharply  defined. 

On  the  other  hand,  these  cells  approximate  to  the  character  of  the 
pus-cell,  the  nucleus  exhibiting,  with  the  disappearance  of  the  cell-wall, 
to  a  various  extent  the  phenomena  of  denticulation  and  splitting.  It  is, 
in  our  opinion,  the  broken-down  fibrino-croupous  exudate,  either  alone 


PUS,     ICHOR.  119 

or  blended  with  true  pus,  that  constitutes  the  pyin-holding  pus  form.  It 
has  been  stated  that  these  pus-like  exudates  frequently  manifest  a  corro- 
sive, deliquescent  influence  upon  the  textures.  Not  being  organizable, 
they  are  extremely  prone  to  further  decomposition,  and  to  assume  the 
nature  of  ichor.  They  furnish  forth  the  majority  of  cases  of  internal 
suppuration,  of  constitutional  pus  deposits,  of  abscesses. 

Ichor,  which,  in  broken-down  croupous  exudates,  often  closely  resem- 
bles pus  in  appearance,  is  distinguished  from  the  bland  nature  of  true  pus, 
by  its  corroding  influence  upon  the  textures,  and  upon  the  form-elements 
developed  out  of  its  protein  substances.  It  is  only  under  such  a  state  of 
things  that  a  fluid  can  be  recognized  as  ichor.  That  met  with  after  death 
varies  infinitely.  A  chemical  examination  of  it  embodying  what  is  essen- 
tial, and  simplifying  what  seems  differential,  is  still  wanting.  Its  degree 
of  corrosiveness  varies  equally.  Ichorous  exudates  are  now  thin,  serous 
fluids ;  now  albuminous,  viscid,  limpid  or  flocculent,  emulsive  and  fatty, 
thickish,  colorless,  or  yellowish,  yellowish-green,  puriform,  whitish, 
creamy.  Or,  owing  to  the  presence  of  blood-corpuscles  and  of  blood- 
pigment,  they  are  of  variously  shaded  red,  dingy  brown,  greenish-brown, 
chocolate-colored.  Again,  they  are  ammoniacal,  hydro-sulphuretted, 
rancid  or  sour-smelling,  acid  or  alkaline,  and  apt  to  produce  upon  the 
skin  of  the  dissector  a  tingling  or  smarting  sensation.  These  fluids, 
minutely  examined,  are  found  to  contain  variously  sized  elementary  gra- 
nules, down  to  the  finest  molecular  mass,  nuclei  and  cells,  of  the  cha- 
racter of  exudation  and  pus-cells,  partly  stunted  in  their  development, 
partly  owing  to  the  saline,  alkaline,  or  acid  condition  of  the  ichor,  shri- 
velled, jagged,  lax,  diffluent,  the  pus-nuclei  being  in  the  act  of  denticula- 
tion  and  splitting. 

They  further  contain  fibrinous  coagula  of  various  kinds,  in  different 
grades  of  spontaneous  reduction  into  pulpy  masses,  coagula  out  of  casein 
and  pyin  substances. 

Finally,  they  yield  crystalline  salts  and  textural  debris  in  the  act  of 
breaking  down,  blood-corpuscles,  animalcules,  &c. 

Even  ichor  enters  into  combination  with  fibrinous  exudates,  especially 
the  fibrino-croupous ;  and,  just  as  in  the  case  of  pus,  there  is,  besides  the 
fluid  product  ichor,  another  ichor  developed  out  of  consolidated  blastema. 
Having  now  described  both  pus  and  ichor,  this  appears  to  us  a  proper 
place  for  the  establishment  of  certain  marks  necessary  for  a  due  discri- 
mination between  the  two. 

The  bland  properties  of  normal  pus  are  acknowledged ;  but  how  does 
this  characteristic  tally  with  the  manifest  destruction  of  tissues  implicated 
in  the  formation  of  pus  ?  The  following  remarks  may  tend  to  throw 
some  light  upon  this  point  : 

(a.)  The  destruction  attendant  upon  pus-exudation  is  limited  to  ne- 
crosis of  the  textural  elements  involved.  But  this  necrosis  is  due  to  the 
intercepted  supply  of  blood  and  to  forcible  disjunction ;  not  to  that  che- 
mical corrosion  and  that  resolution  of  the  textures  which  result  from  ichor- 
ous  discharge. 

(5.)  That  the  bland  nature  of  pus  is  so  frequently  questioned,  arises 
from  products  being  so  often  regarded  as  pus,  which  are  not  so  in 
reality,  and  which  either  originally  possessed,  or  have  acquired  the  pro- 


120  PUS,     ICHOR. 

perty  of  corrosiveness.  Such  products  very  commonly  form  the  contents 
of  shut  abscesses.  Normal  pus  very  often  acquires  a  corroding  property 
through  long  seclusion  within  abscesses,  which,  when  opened,  forthwith 
secrete  a  normal,  bland  pus. 

One  of  the  most  remarkable  phenomena  in  the  process  of  suppuration, 
is  the  formation  of  flesh  granulations.  These  granulations  present,  with 
reference  to  their  character  and  further  development,  two  marked  dis- 
tinctions : 

(a.)  They  consist,  together  with  a  small  proportion  of  intercellular  or 
bond  substance,  of  primary  cells.  These  cells  emerge,  together  with  the 
pus-cells,  from  a  common  albuminous  blastema,  and  out  of  them  are 
called  forth,  conformably  with  the  laws  of  the  cell  theory,  those  elemen- 
tary fibrils  which  ultimately  compose  the  cicatrix. 

(6.)  They  consist  of  a  fibrinous  blastema  which,  exuding  conjointly 
with  the  pus,  solidifies  upon  the  suppurating  surface,  and  yields,  by 
immediate  splitting,  the  fibrous  texture  of  the  cicatrix.  Into  both  these 
scar-bases  enters  a  new  generation  of  bloodvessels,  answering  to  those  of 
abiding  suppuration.  They  determine  the  healing  of  wounds  by  the 
second  intention. 

The  formation  of  flesh-granules  is  not  decisive  evidence  of  a  bland, 
benignant  pus.  It  may  accompany,  and  even  luxuriate  under,  the  pro- 
duction of  ichor.  In  the  one  case,  however,  the  granulations  are  marked 
by  their  durability,  and  by  their  further  textural  development,  whilst  in 
the  other,  they  form  but  to  be  corroded  and  redissolved  by  contact  with 
the  ichor ous  fluid. 

Flesh-granulations  accompanying  the  production  of  pus  in  or  upon 
heterologous  growths,  have,  for  the  most  part,  the  significance  of  textu- 
ral elements  of  such  growths. 

The  tendency  of  pus  (and  of  ichor)  to  vent  itself  externally,  is  com- 
monly overrated.  Pus  deposits  are  often  deeply  encysted  within  organs 
and  a  passage  to  without  often  needs  to  be  made  artificially,  in  order  to 
prevent  the  fluid  from  burrowing. 

The  assertion  that  extensive  exudates  are  especially  liable  to  become 
converted  into  pus,  is  ill  founded,  if  magnitude  of  the  exudate  be  the 
assumed  condition  of  such  conversion.  Doubtless  what  led  to  the  opinion, 
was  the  liquefaction  of  the  commonly  very  massive  croupous  exudates, 
together  with  the  circumstance  that  pus-blastema,  either  pure  or  com- 
bined with  croupous  fibrin,  very  often  becomes  effused  in  great  quantity. 
Apart,  however,  from  quantity,  the  puriform  quality  of  an  exudate  is 
invariably  due  to  inflammatory  stasis.  This  alone,  and  not  the  quantity, 
can  determine  the  development  of  the  elements  of  pus. 

Purulent  and  ichorous  exudates  are  met  with  not  alone  in  the  locali- 
ties assigned  to  normal  pus.  They  often  occur  in  great  quantity  upon 
serous  and  synovial  membranes,  and  in  areolar  tissue,  more  especially 
the  subcutaneous  and  submucous,  as  also  in  certain  of  the  more  lax, 
deep-seated  collections  of  this  tissue,  for  example,  in  the  mediastina,  in 
the  posterior  circumference  of  the  caecum,  around  the  rectum,  and  the 
like.  Lastly,  they  take  place  upon  mucous  membranes,  within  soft 
parenchymata,  and  in  bone. 

The  following  are  the  metamorphoses  which  the  said  exudates,  if  not 
excreted,  undergo : 


(a.)  Tram 


PUS,    ICHOR.  121 


(a.)  Transformation  of  texture,  appearing,  after  the  process  above 
described,  in  the  form  of  so-called  granulations. 

(b.)  Dissolution  affects  both  the  form-elements  (cells,  nuclei),  and  the 
fluid  intercellular  substance,  in  the  shape  of  various  unknown  chemical 
transformations.  Under  this  head  may  be  brought  the  septic  decompo- 
sitions, suffered  by  these  exudates  under  peculiar  circumstances ;  for 
instance,  through  long  stagnation,  through  contact  with  the  atmosphere, 
through  the  effect  of  medicinal  substances,  and  the  like.  These  may 
cause  the  degradation  of  bland  pus  into  ichor,  and  of  ichor  a  step  lower 
in  the  scale. 

(<?.)  Fatty  conversion  in  the  formative  process  of  granule-cells,  fre- 
quently combined  with  the  simultaneous  deposition  of  the  salts  of  lime, 
(cretefaction). 

(d.)  Resorption. 

The  manifold  ways  in  which  pus  substantively,  or  as  pus-serum,  enters 
the  circulation,  and  there  occasions  pyaemia,  cannot  at  all  concern  us  here. 
They  were  before  adverted  to,  and  will  be  further  and  more  amply 
noticed  under  the  head  of  Pyaemia. 

Here  we  have  to  consider  the  resorption  of  pus  in  a  more  restricted 
sense,  and  irrespectively  of  pyaemia. 

This  resorption  can  apply  only  to  the  serum  or  plasma  of  pus.  To 
pus  or  ichor  in  their  totality,  that  is  to  say,  their  form-elements  included, 
it  can  only  apply  after  they  have  undergone  liquefaction  or  fatty  con- 
version. Upon  the  mode  of  liquefaction  depends,  in  the  case  of  pus,  the 
nature  of  the  consecutive  phenomena.  If  it  consist  in  a  putrid  decom- 
position, the  noxious  effects  of  septic  poisoning  of  the  bood  may  ensue. 

Pus  may  either  become  completely  reabsorbed,  or  leave  within  its 
former  nidus  a  residue  of  fat  in  the  shape  of  discrete  or  aggregate  fat 
molecules  and  cholesterine  crystals,  within  a  glutinous  fluid,  or  in  the 
shape  of  chalk  incrustation  and  concretion. 

The  depot  of  pus  and  of  ichor  (abscess)  heals,  through  the  subsidence 
of  pus  and  ichor  production,  and  through  the  organizable  products  of  in- 
flammation existing  in  the  walls  of  the  abscess,  with  new  supplementary 
ones,  undergoing  transformation  into  vascularized  textures.  Pending 
this  act,  the  contents  of  the  depot  are  in  the  manner  before  specified, 
entirely  or  partially  reabsorbed.  According  to  the  measure  of  resorp- 
tion, the  walls  of  the  abscess  shrink  together  and  ultimately  coalesce  into 
a  solid  cicatrix,  or  else  include  an  inspissated  fatty  or  chalky,  or  lardo- 
cretaceous  residue  of  the  primitive  contents. 

Pus  and  ichor  are  the  product,  at  one  time  of  a  mere  local  inflamma- 
tory stasis,  at  another  time  of  a  localized  pre-existent  crasis,  namely, 
general  pyaemia.  In  the  latter  case,  the  production  is  characterized  by 
the  rapidity  of  its  occurrence. 

Suppuration  in  open  abscesses  and  upon  granulating  sores  is  peculiarly 
chronic  in  its  course.  This  process  manifests  itself  as  a  protracted  stasis, 
communicated  from  the  original  textures  to  the  embryonic  new  growths 
which  the  granulations  with  their  newly  acquired  vascular  apparatus 
have  given  rise  to.  Taken  in  another  point  of  view,  the  granulations 
appear  to  stand  to  pus-formation  in  a  relation  which  earlier  pathologists 
signified  by  the  terms  pyogenous  membrane,  a  pus-secreting  apparatus. 


122  HEMORRHAGIC    EFFUSION. 

Looking  at  the  often  slight  intensity  of  the  inflammatory  symptons,  the 
analogy  between  a  granulating  wound  (abscess)  and  a  secreting  organ, 
— between  pus  and  a  secretion  prepared  by  those  elementary  bodies, 
cells,  appears  so  great,  and  the  current  comparison  with  a  mucous  mem- 
brane and  its  product  so  apt,  as  forcibly  to  recur  to  us,  even  at  the 
present  day.  Thus,  no  sooner  have  the  growths  which  presided  over  the 
secretion — in  other  words,  the  granulations — become  exalted  into  tex- 
tures, than  the  secretion  itself  fails. 

Referring  certain  particulars  connected  with  the  anatomical  doctrine 
of  exudates  to  the  head  of  crasis,  we  have  still  to  consider,  as  kindred 
with  ichorous  exudates,  diffluent  exudates,  and  with  them  hemorrhagic 
effusion. 

(a.)  Solvent  exudates.  Akin  to  ichorous  exudates,  they  are  marked 
by  their  destructiveness  to  subjacent  textures,  by  the  obviously  solvent 
character  of  their  effects,  and  by  the  absence  of  any  outward  tokens  to 
denote  their  mischievous  character. 

These  are  products  which,  owing  to  the  corrosion  of  textures  accom- 
panying the  very  act  of  their  exudation,  are  rarely  to  be  met  with  in 
their  simplicity,  products  which  display  immense  variety  in  their  physi- 
cal properties.  As  the  extreme  limits  of  a  long  series,  we  find,  on  the 
one  side,  a  coagulable,  fibrinous  exudate  which  has  the  effect  of  slightly 
corroding  the  subjacent  membranous^substance.  On  the  other  side  we 
have  a  thin  exudate,  variously  discolored,  which  reduces  the  textures, 
extensively,  to  a  dingy  brown,  chocolate-colored,  inky  (hemorrhagic),  or 
greenish,  pulpy,  tinderlike,  fetid,  slough.  This  last-mentioned  exudate 
represents  the  processes  which  Boer  described  in  the  uterus  as  putres- 
cence, a  term  quite  deserving  of  application  to  the  same  condition  in 
other  parts.  Midway  between  these  two  extremes,  we  encounter  the 
most  remarkable — however  seemingly  insignificant — thin,  serous,  sero- 
albuminous,  tenacious,  paste-like,  sero-purulent,  almost  colorless,  or 
again  yellowish,  reddish-yellow,  exudates,  in  contact  with  which  the 
textures  are  resolved  according  to  their  degree  of  injection,  into  a  pale, 
or  into  a  more  or  less  deeply-reddened  pulp. 

Their  seat,  always  diffuse,  is  most  particularly  the  mucous  membrane 
of  the  intestinal  tract,  and  most  commonly  of  the  colon,  not  rarely  of 
their  follicles  (in  the  shape  of  diarrhoea  or  dysentery),  and,  lastly,  of  the 
uterus,  as  puerperal  affections  following  childbirth.  Of  the  principle 
upon  which  this  liquefiant  destruction  of  the  tissues  depends,  nothing  is 
known  beyond  its  frequent  acid  reaction,  nor  has  any  crasis  correspond- 
ing to  it  been  recognized. 

(b.)  The  hemorrhagic  exudate. 

It  is  indispensable  in  the  first  place  to  discriminate  between  exudates 
reddened  by  blood-pigment  only,  and  those  which  contain  substantive 
blood,  that  is,  blood-corpuscles. 

The  former  are  met  with  in  all  dyscrases,  both  acute  and  chronic,  in 
which,  owing  to  defibrination,  to  decomposition  of  the  fibrin,  or  to  dimi- 
nished proportion  of  salts,  blood-pigment  is  transferred  from  the  blood- 
corpuscles  to  the  blood-serum.  Thus,  exudates  occurring  during  the 
progress  of  scurvy,  of  typhus,  of  gangrene,  of  the  drunkard's  dyscrasis, 
of  putrid  exanthemata,  are  stained  with  adherent  blood-pigment.  Those 


HEMORRHAGIC     EFFUSION.  123 


containing  blood  in  its  totality,  and  the  red  color  of  which  results  from 
blood-corpuscles,  are  the  true  hemorrhagic  exudates. 

Holding  fast  this  distinction,  we  shall  be  enabled  partly  to  infer  from 
physiological  reasoning,  partly  to  prove  by  the  exact  method,  the  origin 
and  import  of  hemorrhagic  effusion. 

We  have  seen  that,  in  every  inflammation,  at  the  stage  of  congestion 
and  stasis,  there  occur  extravasations  of  blood,  proportionate  in  extent 
to  the  vascularity  of  the  organ,  to  the  magnitude  of  its  congestion  and 
stasis,  and  lastly,  to  the  laxity  and  vulnerability  of  its  texture.  That  this 
bleeding  takes  place  out  of  lacerated,  or  in  somewise  opened  vessels  by 
extravasation,  and  not  by  transudation,  is  evident  from  the  absence  in 
the  walls  of  bloodvessels  of  pores  equal  to  the  transudation  of  blood-cor- 
puscles. This  is  the  rule  with  respect  to  hemorrhage  in  textures  like 
those  of  the  brain  or  the  lungs.  The  difficulty  is,  and  always  has  been, 
to  explain  hemorrhagic  effusion  occurring  upon  serous  membranes, — a 
formation  so  given  to  effusion  in  no  way  hemorrhagic.  Upon  this  point 
it  is  to  be  observed  : 

(a.)  A  primitive  genuine  hemorrhagic  exudate  (not  merely  blood- 
stained), if  it  really  ever  occur  upon  serous  membranes,  occurs  only  as 
a  rare  exception. 

(b.)  Hemorrhagic  exudates  upon  serous  membranes  are,  almost  with- 
out exception,  the  result  of  hemorrhage  from  the  bloodvessels  of  a  spuri- 
ous membrane  in  the  act  of  becoming  organized  ;  in  other  words,  from 
the  product  of  a  previous  inflammation  of  the  serous  tunic.  This  hemor- 
rhage may  be  an  independent  act,  or  it  may  be  the  concomitant  of  in- 
flammation propagated  from  the  serous  coat  to  its  pseudo-membranous 
duplicate.  This  is,  in  fact,  usually  the  case.  Such  exudates  are  secon- 
dary ones. 

The  facility  with  which  hemorrhage  takes  place  from  these  new  growths, 
is  explicable  on  the  ground  of  their  imperfect  organization,  both  as 
regards  change  of  texture  and  the  development  of  bloodvessels.  An 
inflammation  early  set  up  in  such  a  new  formation,  encounters  a  lax, 
soft,  lacerable  growth,  involving  an  incomplete,  soft,  and  delicately 
membraned  vascular  apparatus,  with  anastomoses  as  yet  unclosed  ;  blood- 
vessels which,  when  urged  into  congestion  and  stasis,  readiy  give  way, 
or  possibly  force  a  passage  from  their  free  and  as  yet  unanastomosed 
ends  into  the  substance,  and  through  this  into  the  cavity,  of  the  serous 
membrane. 

Accordingly,  under  these  stereotype  conditions,  hemorrhagic  exuda- 
tion is  precisely  what  extravasation  is  during  the  course  of  an  inflamma- 
tion in  the  laxer  textures,  namely,  exudation  plus  hemorrhage. 

Hemorrhage  being,  however,  the  consequence  not  alone  of  mechanical 
laceration,  but  also  of  a  softening  or  a  corrosion  of  the  vessels,  it  is  intel- 
ligible how  ichorous  exudates,  and  the  solvent  exudates  generally,  may 
put  on  a  hemorrhagic  character. 

Hemorrhagic  exudation  seems  to  stand  in  an  especial  relation  to  tuber- 
culosis, and  is  dreaded  chiefly  because  the  latteris  assumed  to  be  its  source. 
It  is  important  to  be  clear  upon  this  point : 

(a.)  It  is  quite  true  that  it  is  very  frequently  a  partially  tuberculized 


124  ISSUES    OF    INFLAMMATION. 

new  growth  (pseudo-membrane)  in  which  the  hemorrhagic  process  occurs. 
Still  there  are  very  notable  exceptions  to  this. 

(5.)  Tuberculized  growths  appear  to  be  peculiarly  liable  to  inflam- 
mation ;  tubercle  being  wont  to  set  up  reactive  processes  of  inflammation 
everywhere  in  its  circumference. 

In  this  way  the  hemorrhagic  inflammatory  process  often  concurs  with 
local  tuberculosis,  without  directly  depending  upon  the  tuberculous  crasis. 
That  tuberculosis  acts  as  the  source  of  hemorrhagic  effusion  is  rendered 
probable  by  experience,  but  it  is  by  no  means  proved. 

In  like  manner,  hemorrhage  and  hemorrhagic  exudation  break  forth 
in  the  midst  of  carcinomatous  growths,  or  in  pseudo-strata,  of  the  same 
character,  upon  mucous  membranes  or  within  serous  sacs. 

In  quantity,  the  extravasate  mingling  with  the  exudate  varies  consi- 
derably, and  it  may  be  either  intimately  blended  both  with  the  coagula 
and  with  the  fluid  portion  of  the  exudate,  or  separated  from  it  in  the 
shape  of  pellet-like  clots. 

Apart  from  the  aforesaid  conditions  of  its  appearance,  and  of  its  rela- 
tion to  tuberculosis,  it  is  of  evil  omen  only  in  proportion  to  the  loss 
of  blood  entailed  by  it,  and  to  the  previously  reduced  vital  strength 
of  the  patient. 

The  hemorrhagic  exudate  is  not  organizable,  or  only  very  tardily  so. 
This  refers  more  particularly  to  the  exudate  ;  the  blood-corpuscles  after 
long  remaining  unaltered  at  length  become  dissolved,  leaving  their  pig- 
ment to  undergo  the  changes  elsewhere  described.  The  exudate  portion, 
answering  to  the  character  of  its  base,  very  commonly  retains  its  rudi- 
ment al  condition,  which  in  the  majority  of  cases  is  tuberculous. 

It  would  seem  advantageous,  before  concluding,  to  revert  to  a  few 
points  already  touched  upon,  relative  to  the  habitudes  of  exudates  in  and 
upon  diseased  structures. 

Exudates  are  deposited  more  or  less  uniformly  between  the  elementary 
parts  of  textures.  This  is  contingent  upon  the  more  or  less  uniform 
density  and  cohesion  of  the  textures,  as  also  upon  the  number  of  bloodves- 
sels present,  and  their  mode  of  distribution  ;  for  example,  the  striated  exu- 
dates, following  the  linear  arrangement  of  the  bloodvessels  in  tendons 
and  ligaments. 

When  copious  effusion  takes  place  suddenly  and  violently  in  the  laxer 
structures,  for  example,  in  the  brain,  the  exudate  becomes  established 
through  the  forcible  separation  and  laceration  of  the  natural  textures. 

In  the  inflammation  of  membranes  the  exudate  is,  as  we  have  stated, 
for  the  most  part  thrown  out  upon  the  free  surface.  In  the  inflamma- 
tion of  glands  similar  effusion  takes  place  into  their  respective  cavities — 
the  uriniferous  tubules,  Malpighian  bodies,  and  the  like. 

Coagulable  exudates  solidify  upon  the  surface  of  inflamed  membranes, 
and  are  commonly  termed  spurious  membranes.  Upon  serous  membranes 
they  occasion  agglutination  of  the  serous  surfaces. 

ISSUES   OF   INFLAMMATION. 

The  so-called  issues  of  inflammation  comprehend  a  variety  of  pro- 
cesses. They  concern  either  the  inflammation  itself  or  its  products  and 


ISSUES    OF    INFLAMMATION.  125 

involved  structures  ;  that  is  to  say,  they  embrace,  in  the  latter  rela- 
tion, the  changes  which  both  the  inflammatory  products  and  the  textures 
themselves  undergo. 

To  the  former  category  belong : 

1.  Resolution  or  dispersion  of  the  inflammation. 
To  the  second  belong : 

2.  Reliquefaction  and  resorption  of  the  inflammatory  products. 

3.  Abiding  of  the  inflammatory  products  in  various  forms,  including, 
amongst  others,  the  issue  in  induration,  and  in  inflammatory  hypertrophy. 

4.  Suppuration,  ichorous,  ulcerous  destruction  of  textures. 

We  cannot  ourselves  regard  suppuration  as  an  issue  of  inflammation. 
Wherefore  we  have  treated  of  pus  and  ichor  as  of  products  of  inflamma- 
tion, under  the  head  of  "  exudates." 

Of  the  issue  of  inflammation  in  gangrene,  of  so-called  inflammatory 
gangrene,  we  cannot  well  treat  separately.  We  therefore  refer  the  con- 
sideration of  this  point  to  a  subsequent  chapter,  to  be  devoted  to  the 
subject  of  gangrene. 

1.  Resolution  of  the  inflammation. — Issue  in  resolution  relates  di- 
rectly to  the  inflammatory  process.  It  consists  in  a  cessation  of  the 
latter,  previously  to  any  act  of  effusion ;  that  is,  in  a  reduction  of  the 
existing  stasis. 

As  determining  conditions,  we  may  adduce : 

(a.)  Cessation  of  the  efficient  cause  of  inflammation  ;  and,  as  a  conse- 
quence, cessation  of  the  palsy  of  the  bloodvessels,  and  returning  contrac- 
tility of  the  latter. 

(b.)  Reinforced  impulse  from  the  arteries,  brought  about  by  the  said 
contractility  of  the  capillaries,  one  effect  of  which  is  a  return  of  the  pheno- 
menon of  oscillating  motion  in  the  arrested  blood-column. 

(<?.)  Liberation  of  the  blood-corpuscles  from  a  state  of  mutual  cohesion, 
through  endosmosis  of  the  exuded  blood-serum  into  the  vessels  charged 
with  concentrated  plasma.  The  blood-corpuscles  lose  the  flattened  con- 
dition and  deep  color  which  they  had  acquired  in  the  stasis,  swell  out, 
and  become  spherical  and  at  the  same  time  paler. 

(d.)  The  uninterrupted  circulation  in  the  capillaries  surrounding  an 
inflammation,  plays  its  part  likewise,  portions  of  the  stagnant  blood- 
column  being  (according  to  Emmert)  forcibly  separated  by  the  laving 
current,  and  a  passage  forced  here  and  there  through  an  entire  capillary 
range. 

Obstacles  sometimes  present  themselves  to  the  resolution  of  inflamma- 
tion ;  and  even  when  the  process  is  accomplished,  certain  residua  are 
left  behind : 

(1.)  The  blood-corpuscles  are  so  firmly  wedged  in  the  dilated  capilla- 
ries, as  to  resist  both  the  contraction  of  the  latter  and  the  increased 
impulse  from  the  arteries.  This  occasions  a  protracted  stasis  of  a 
mechanical  nature. 

(2.)  Even  after  removal  of  the  stasis,  a  certain  degree  of  palsy  and 
dilatation  of  the  capillaries  may  remain  entailed.  The  part  previously 
inflamed  continues  in  a  state  of  hypersemia,  and  prone  to  relapse  into 
inflammation.  This  tendency  increases  greatly  upon  repetition.  The 


126  ISSUES     OF    INFLAMMATION. 

resolution  of  local  inflammations  dependent  on  external  causes,  is  com- 
mon only  where  these  causes  are  slight. 

Inflammations  dependent  upon  internal  dyscrasial  influences  rarely 
terminate  thus.  An  essential  condition  of  their  so  doing  is  the  extinc- 
tion of  the  dyscrasis.  If  without  this  the  inflammation  take  such  an 
issue,  it  will  localize  itself  in  other  organs  standing  in  the  relation  of 
sympathy  with  that  originally  affected. 

Even  this  favorable  consummation  of  the  inflammatory  act  is  not  a 
matter  of  indifference  for  the  organism,  seeing  that  plasma,  altered  by 
the  previous  stasis,  is  copiously  received  back  again  into  the  blood. 
The  consequences  are  obvious,  and  directly  commensurate  with  the 
extent  of  the  inflammation. 

2.  Reliquefaction  and  resorption  of  the  inflammatory  products. — 
This  issue  of  inflammation  is  contingent  upon  previous  exudation,  and 
consists  in  resorption  of  the  products.     It  takes  place  with  greater  or 
less  facility,  according  to  the  measure  of  the  exudation,  and  to  its  degree 
of  solidification.     It  succeeds  either  completely  or  incompletely,  and 
hereupon  it  depends,  whether  in  the  sequel  the  diseased  organ  recovers 
its  normal  condition  altogether,  or  only  partially  and  imperfectly. 

Fluid  exudates  are  naturally  susceptible  of  resorption. 

Solid  exudates  become  adapted  for  resorption  by  preliminary  solu- 
tion,— corrosion  through  blood-serujn, — or  else  by  disintegration,  with 
various  changes  in  their  chemical  composition. 

Elementary  bodies  must  be  previously  dissolved,  in  order  to  become 
adapted  for  resorption,  which  process  takes  place  both  through  the 
bloodvessels  and  the  lymphatics. 

The  consequences  of  resorption  differ  with  the  primitive  quality  of  the 
exudate,  with  the  mode  of  its  preliminary  solution  and  of  its  chemical 
transformation,  and  with  the  quantity  reabsorbed.  Finally  they  differ 
accordingly  as  the  resorption  takes  place  chiefly  through  the  lymphatics 
or  directly  into  the  sanguineous  current. 

In  this  issue  of  inflammation  is  comprehended  wasting  of  the  textures 
through  inflammation.  It  consists  in  the  elements  of  the  textures  being 
themselves  liable  to  become  reabsorbed  along  with  the  products  of  inflam- 
mation. This  is  owing  to  the  textural  elements,  within  the  range  of  in- 
flammation, becoming  functionally  disabled  by  mechanical  pressure,  to 
the  impediment  to  their  nutrition  offered  by  the  effusion ;  the  result 
being  the  dissolution  and  resorption  of  those  elements.  This  termina- 
tion is  especially  frequent  in  delicate,  vulnerable  textures,  in  very 
copious  effusion,  and  where  the  latter,  being  solidified,  is  susceptible  only 
of  very  tardy  resorption.  In  this  manner  is  the  substance  of  the  brain, 
of  muscle,  of  kidney,  and  the  like,  destroyed  within  the  range  of  inflam- 
mation, its  place  becoming  occupied  by  a  cavity,  or  by  multilocular 
cavities  bounded  by  scar  texture.  Where  these  are  small  and  numerous, 
they  beget  a  loosening,  a  rarefaction  of  the  textures,  as,  for  example,  in 
the  condition  termed  cell-infiltration  in  the  brain.  In  hollow  structures, 
for  example  the  Graafian  vesicles,  the  contents,  altered  by  the  exudate 
and  its  metamorphoses,  are  absorbed,  and  the  organ  becomes  extinct. 

3.  Abiding  of  the  inflammatory  product. — The  products  of  inflamma- 
tion are  retained  bodily,  or  after  imperfect  resorption,  partially,  in  their 


ISSUES    OF    INFLAMMATION.  127 


original,  or  it  may  be  in  an  altered  shape  and  constitution.     Confor- 
mably with  what  has  been  stated,  the  exudates  continue — 

1.  In  their  original  crude  state,  as  entirely  amorphous  masses,  or  more 
commonly  in  a  condition  bordering  upon  this,  of  incipient  textural  de- 
velopment, in  the  shape  of  molecular  granules,  of  nucleus  and  cell-for- 
mation, or  in  the  case  of  consolidated  blastemata,  in  the  laminated  and 
fibrous  structure  engendered  by  the  coagulative  process  itself. 

2.  Or  they  break  up  sooner  or  later,  and  abide  in  a  state  of  final  cre- 
taceous or  fatty  conversion. 

3.  Solid  exudates  waste  away,  and  condense  and  shrivel  into  a  horny 
substance. 

4.  They  become  organized,  attaining  thus  to  various  grades  of  de- 
velopment.    In  fluid  exudates  this  development  follows  the  laws  of  the 
cell  theory,  whilst,  in  the  organizable,  solid,  fibrin-exudates  it  consists  in 
immediate  fibrillation  through  dissilience. 

The  exudates  enter,  bodily,  into  a  uniform  textural  change.  This 
change  may,  however,  conformably  with  the  frequent  primitive  impurity 
of  blastemata,  be  in  many  cases  unequable.  One  portion  of  the  exudate 
may  attain  a  higher  gradation  and  represent  permanent  textures,  whilst 
another  may  be  arrested  at  an  embryonic  stage,  and  there  liquefy  and 
become  reabsorbed,  or,  like  pus  and  ichor,  qualify  itself  essentially  for 
excretion. 

A  textural  conversion  of  exudates  may  be  of  a  nature  very  similar  to, 
if  not  identical  with,  the  normal  structure,  in  its  anatomical,  chemical, 
and  functional  relations.  Or,  again,  it  may  involve  one  or  more  hetero- 
logous  formations,  pus  and  cancer,  for  instance. 

It  is  more  particularly  areolar  tissue,  and  the  various  fibroid  textures 
tending  to  the  final  composition  of  the  latter ;  cartilage  in  the  process  of 
ossification  ;  and  bone  with  its  penetrating  vessels,  that  are  here  referred 
to  as  organized  products  of  inflammation. 

These  often  serve  to  compensate  for  lost  parts,  as  also  for  the  filling 
up  of  vacant  spaces  wrought  by  the  retraction  of  normal  textures  after 
injuries,  regeneration  in  muscles  for  instance. 

The  regeneration  is  complete  ;  or  it  is  imperfect,  being  accomplished 
by  means  of  a  texture  not  homologous  with  the  lost  one, — as  in  the 
cicatrix.  This,  again,  may  be  permanent,  or  it  may  be  provisional  only, 
and  about  to  disappear  after  becoming  endowed  with  textural  elements 
identical  with  the  normal  ones, — the  nerve-cicatrix,  for  example. 

Where  permanent  exudates  do  not  serve  for  compensation,  they  occa- 
sion an  increase  of  mass  in  the  diseased  organ.  They  are  then — 

(a.)  Uniformly  interposed  between  the  elements  of  the  normal  texture. 
This  determines  an  inflammatory  hypertrophy,  which,  perhaps,  occurs 
in  a  genuine  form  only  in  areolar  tissue  and  in  bone. 

(b.)  Or  they  form  in  a  larger  circumscribed  mass,  distinct  from  the 
normal  texture, — a  tumor.  These  local  collections  of  cicatrix  texture 
occur  in  muscle  (the  heart)  and  in  all  parenchymata.  Upon  serous 
membranes,  they  constitute  the  various  organized  pseudo-membranes  and 
membranaceous  adhesions.  We  have  here  further  to  remark : 

1.  In  bulky,  and  particularly  in  solid,  wasting  exudates,  or  such  as 
are  in  progress  of  transformation  into  dense,  shrivelling  (fibroid)  struc- 


128  GANGRENE,    NECROSIS. 

tures,  any  textural  elements  which  they  have  embraced  become  atrophied 
by  pressure  and  tension,  hindrance  to  their  nutrition,  and  the  suppres- 
sion of  their  function.  Even  contiguous  textures  waste  away,  owing  to 
arrested  or  impaired  function — for  instance,  the  muscular  apparatus  of 
respiration  over  thick,  resistent,  shrivelling,  pleuritic  effusion. 

2.  In  hollow  organs  the  abiding  of  exudates  not  rarely  occasions  a 
hypertrophic  development  to  cystiform  dilatations,  with  transformation 
of  the  texture  of  their  walls  and  contents.     As  examples,  we  may  refer 
to  the  degradation  of  glandular  acini,  and  of  the  follicles  into   cysts. 
(See  Cyst.) 

3.  Solid   exudates   determine,   through    increased   consistency   and 
density  of  the  textures  previously  inflamed,  the  issue  of  the  inflammation 
in  so  termed  induration.     On  the  other  hand,  the  abiding  of  soft  liquid 
exudates  results  in  relaxation,  softening,  lacerability  of  the  textures. 

4.  Exudates  are  often  found  to  linger  under  several  combined  forms, 
with  which,  moreover,  both  resorption  and  suppuration  may  have  con- 
curred. 

4.  Ulceration,  Ichorous  destruction. — It  consists  in  a  wasting  of  the 
textures  from  the  corrosive  quality  of  the  exudate.  Herein  ulcerous 
consumption  of  the  textures  differs  from  the  loss  of  substance  which  in- 
flamed textures  undergo,  within  the  best  conditioned  exudates,  through 
necrosis  and  absorption. 

To  be  productive  of  such  a  wasting  process,  the  exudate  must  needs 
be  fluid,  whether  originally  so,  or  liquefied  out  of  a  solid  blastema.  Its 
corrosive  influence  upon  the  textures  is  sufficient  to  confirm  its  character 
as  genuine  ichor. 

The  mode  in  which  textures  in  contact  with  ichor  become  destroyed, 
varies  with  the  principle  upon  which  its  corrosive  nature  depends.  The 
exulceration  takes  sometimes  an  acute,  sometimes  a  chronic  course. 
Large  textural  masses  are  not  rarely  destroyed  within  a  short  space  of 
time.  The  destruction  is  marked,  now  by  superficial  extension,  now  by 
a  burrowing  propensity.  In  the  former  instance,  it  depends  frequently 
upon  a  special  relation  of  the  inflammatory  process  to  superficial  textu- 
ral expansion.  In  the  other  case,  some  heterologous  formation,  repro- 
duced again  and  again,  at  the  base  of  the  ulcer,  upholds  the  inflamma- 
tion, and  with  it  the  ichorous  discharge. 

In  the  chronic  form,  the  ulcer,  like  the  pus-membrane,  simulates,  in 
the  production  of  flesh-granules,  a  natural  process  of  secretion. 

All  textures  are  not  equally  prone  to  ulcerative  destruction.  Under 
like  circumstances,  tender,  young,  budding  growths  are  the  most  readily 
destroyed. 

GANGRENE,   NECROSIS. 

Under  gangrene,  necrosis,  is  understood  the  death  of  an  organ  or  part, 
as  manifested  by  the  more  or  less  rapid  breaking  down  and  chemical 
decomposition  of  its  texture.  Gangrene  may  affect  both  soft  and  solid 
structures,  the  bones,  for  instance,  or  even  fluids,  as  in  necrosis  or  sepsis 
of  the  blood.  The  breaking  down  of  solid  structures,  is  generally  a  slow 
process,  whilst  in  soft,  juicy  textures,  and  in  fluids,  it  is  rapidly  con- 


GANGRENE,     NECROSIS.  129 

summated.  Like  normal  textures,  new  formations  of  every  kind, — 
tumors,  exudates,  pus, — are  liable  to  become  necrosed.  Fluids  degene- 
rate through  necrosis  to  gangrenous  ichor,  the  most  infectious  and  de- 
structive of  its  tribe. 

A  general  characteristic  of  gangrene  is  not  easily  given,  so  manifold 
are  its  forms,  and  so  various  its  causes.  Soft  parenchymata  commonly 
break  down  to  a  diffluent  pulp,  marked  by  a  high  degree  of  discoloration 
and  of  fetor.  Exceptions  are,  however,  numerously  afforded  in  gangrene 
of  the  bones,  mummifying,  white  gangrene. 

Gangrene  has  the  import  sometimes  of  a  local,  sometimes  of  a  symp- 
tom of  general  disease.  The  conditions  necessary  to  the  former  case 
are  nearly  reducible  to  arrested  afflux  of  blood,  that  is,  stasis.  It  may 
begin  by  attacking  fluid  parts,  and  especially  the  blood,  and  extend  from 
these  to  solid  structures,  or  it  may  affect  them  all  at  once. 

Gangrene  is  developed — 

1.  Out  of  absolute  blood-stasis,  which  may  occur  under  various  cir- 
cumstances : 

(a.)  Every  hypersemia  in  organs,  or  sections  of  organs,  paralyzed  or 
enfeebled,  or  obnoxious  to  debilitating  influences,  may  degenerate  into 
absolute  stasis.  This  applies  particularly  to  asthenic,  hypostatic  hyper- 
aemia  in  torpid  peripherous  organs,  vegetating,  so  to  say,  imperfectly 
under  the  embarrassment  of  continued  pressure. 

(b.)  Mechanical  hypenemia  frequently  becomes  absolute  stasis,  as 
observed  in  incarcerated,  strangulated  organs,  and  as  a  consequence  of 
extensive  plugging  of  the  returning  vessels  in  the  lower  extremities. 

(c.)  Every  inflammatory  stasis  may  degenerate  into  absolute  stasis, 
more  particularly  those  hypostatic  and  asthenic  inflammations  which 
occur  in  organs  already  diseased,  paralyzed,  or  depressed  by  violent 
external  influences,  such  as  concussion,  contusion,  cold,  or  heat.  An 
inflammation  consequent  upon  influences  directly  or  indirectly  debilita- 
ting, may  acquire,  during  its  progress,  a  tendency  to  absolute  stasis. 

In  absolute  stasis,  the  blood  undergoes  gangrenous  decomposition. 
Hence  the  blood  is  the  portion  originally  necrosed  and  dissolved.  It 
exudes  in  a  state  of  gangrenous  decomposition,  and  in  the  form  of  ichor, 
through  the  walls  of  bloodvessels,  engendering  the  same  gangrenous  de- 
composition both  in  these  and  in  the  surrounding  textures.  This  event 
gives  rise  to  the  most  ordinary  and  most  developed  form  of  moist  gan- 
grene, in  which  the  textures  are,  through  the  medium  of  the  blood, 
broken  down  to  a  dark-colored,  friable  and  lacerable,  diffluent,  and  highly 
fetid  pulp.  The  dark  discoloration,  however,  of  gangrene  thus  developed, 
is  subject  to  various  modifications  due  to  certain  elementary  products, 
which  the  inflammatory  stasis  has  generated  both  within  the  bloodvessels 
and  without. 

The  progress  of  this  gangrene  is  more  or  less  acute,  the  gangrenous 
dissolution  of  tissues,  already  referred  to  under  the  term  putrescence, 
being  particularly  marked  by  the  rapidity  of  its  course. 

2.  G-angrene  is  determined  by  failure  in  the  supply  of  blood : 

(a.)  In  impermeability  of  large  arteries, — high  degree  of  coarcta- 
tion,  and  complete  obstruction — consequent  upon  arteritis  and  ossifica- 
tion. 

VOL.  I.  9 


130  GANGRENE,    NECROSIS. 

Here  the  gangrene,  for  the  most  part,  takes  the  form  of  comparatively 
dry,  black,  mummifying  gangrene. 

(b.)  As  the  result  of  the  immediate  compression  and  tension  of  a  part; 
for  instance,  in  incarcerated  hernia. 

(c.)  As  a  consequence  of  the  local  destruction  of  bloodvessels,  the 
denudation  of  parts  of  attaching  and  blood-supplying  textures, — bones, 
for  example,  of  their  external  and  internal  periosteum  ;  the  common  in- 
teguments, of  their  supporting  areolar  tissue ;  the  peritoneum,  of  its 
subjacent  layers ;  isolation  of  the  pulmonary  pleura  over  cavities  of  the 
lung. 

The  gangrene  appears  as  a  white  or  yellowish-white  slough. 

To  this  category  belongs  the  necrosis  of  smaller  textural  parts, 
loosened  mechanically  by  exudation  or  by  ulceration. 

(d.)  Extensive  impermeability  of  the  capillaries  and  minute  vessels 
when  plugged  with  coagula,  or  compressed  by  surrounding  exudates. 

In  the  last-mentioned  case,  the  gangrene  is  dependent  upon  inflamma- 
tion. To  this  kind  of  gangrene,  textures  poor  in  bloodvessels,  such  as 
compact  bones,  callosities,  &c.,  are  especially  obnoxious.  The  color  of 
the  necrosed  textures  differs  with  the  different  nature  of  the  coagulation, 
and  of  its  exudate.  Answering  to  the  croupous  character  of  bulky 
exudates,  the  textures  involved  in  the  necrosis  commonly  assume  a  yellow 
or  yellowish-green  hue. 

3.  The  gangrene  is  the  expression]  the  localization  of  an  anomaly  in 
the  blood-erase,  either  directly  ingrafted  by  infection  (contagion),  or 
developed  out  of  other  erases ;  a  putrid  decomposition  of  the  circulating 
fluid.  Blood  so  poisoned,  especially  if  brought  into  stasis  or  into  coagu- 
lation, possesses,  in  common  with  the  exudates  thrown  out  by  it,  an  in- 
herent tendency  to  gangrenous  dissolution. 

It  has  been  already  stated,  that  several  varieties  of  gangrene  are  re- 
cognized : 

1.  G-angrene  developed  out  of  an  internal  cause  is  distinguished,  by 
the  designation  of  primary  gangrene,  from  that  arising  out  of  a  pre- 
dominant external  cause. 

2.  Hot,  acute,  inflammatory  gangrene. — True  gangrene.     In  what 
wise  inflammation  leads  to  gangrene,  is  sufficiently  clear  from  the  fore- 
going. 

(a.)  The  inflammatory  stasis,  owing  to  its  very  intensity,  to  pre- 
existent  debility  of  the  diseased  textures,  or,  lastly,  to  weakening  influ- 
ences exercised  during  its  progress,  degenerates  into  absolute  stasis. 

(b.)  It  occasions  gangrene  by  the  crushing  effect  of  its  products  upon 
the  capillaries,  or  by  the  mechanical  or  ulcerous  isolation  of  textural 
parts. 

In  the  first  case,  the  necrosis  affects  more  immediately  the  blood  held 
in  stasis;  in  the  second,  the  textures.  In  the  first  case  the  gangrene  is, 
as  it  were,  an  immediate  issue  of  the  inflammation,  the  opposite  to  reso- 
lution ;  in  the  second  it  is  a  remote  consequence  thereof. 

In  this  way,  gangrene  may  arise  in  tissues  laboring  under  the  sequelae 
of  inflammation,  without  being  itself  an  issue  of  the  latter. 

3.  Gold  gangrene,  sphacelus,  is  so-called,  as  being  unconnected  with 
inflammation. 


GAXGREXE,     NECROSIS.  131 

4.  Moist  gangrene  comprises  the  breaking  down  of  fluid  substances 
to  gangrenous  ichor,  and  of  fibrin  textures  to  a  variously  discolored, 
diffluent  pulp,  marked  by  its  evolution  of  fetid  gases.  It  is  the  gangrene 
developed  out  of  absolute  blood-stasis; — therefore,  again,  inflammatory 
gangrene.     It  may  be  compared  to  the  decomposition  of  animal  matter 
under  the  co-operating  influence  of  water. 

5.  Dry  gangrene  is  a  consequence  of  deficient   blood  supply.     It 
manifests  itself  in  the  perishing  of  the  implicated  textures,  with  shrivel- 
ling or  withering  thereof,  to  an  incipiently  tough,  but  eventually  sloughing 
mass.     Often,  and  particularly  in  the  gangrene  termed  senile,  which 
affects  the  extremities,  especially  the  inferior,  owing  to  impermeability 
of  their  arteries,  the  gangrenous  textures  blacken ;  wherefore  this  species 
has  been  designated  as  mummifying  gangrene.     As  such,  it  is  compa- 
rable to  the  decaying  of  organic  matter,  that  is,  to  decomposition  with 
absence  or  insufficiency  of  moisture,  and  with  the  disengaging  of  pure 
carbon.     Dry  gangrene  is  frequently  called  gangrenous  slough. 

6.  Black  gangrene,  gangrenous  slough. 

7.  White  gangrene,  gangrenous  slough,  occurs,  for  the  most  part,  as 
a  consequence  of  pressure  in  incarceration  ;  of  the  denuding  of  membra- 
nous expansions  of  their  subjacent  textures,  for  example,  as  peritoneal 
sloughing  at  the  base  of  intestinal  ulcers.     Again,  it  is  generated  by  the 
necrosis  or  death  of  textures  replete  with  fibrino-croupous  exudates,  or 
of  such  coagulate  exudations  themselves.     This  refers  more  particularly 
to  the  common  integuments,  the  mucous  membranes,  fibrous  and  areolar 
tissue  expansions  upon  wounded  and  ulcerated  surfaces.     To  this  head 
belongs  hospital  gangrene. 

Of  these  different  species  of  gangrene,  several  are  ofteji  concurrently 
present.  Beneath  the  common  integument,  often  transformed  into  a 
swarthy  parched  rind,  in  senile  gangrene,  we  frequently  meet  with 
patches  in  which  the  textures  are  reduced  to  a  humid  stinking  pulp. 

Just  as  gangrene  of  the  solids,  gangrenous  slough,  varies,  so  in  like 
manner  does  gangrenous  ichor,  as  necrosed  blood  or  exudate  vary, 
according  to  the  crasis  or  constitution  under  which  either  has  become 
attacked  with  gangrene.  Thus  the  necrosis  of  typhous  blood  differs 
from  that  of  pus-blood,  or  of  fibrino-croupous  blood. 

Like  normal  textures, — diseased  textures  and  new  growths,  fibroid, 
cancerous  formations,  for  example,  may  become  a  prey  to  gangrene. 
Neither  to  ulceration  nor  to  gangrene  are  all  textures  alike  obnoxious. 
Bony,  elastic,  fibrous  textures  resist  gangrene  more  ably  than  muscle, 
areolar  tissue,  or  mucous  membranes.  Lax  embryonic  textures,  as,  for 
instance,  certain  kinds  of  cancer,  are  especially  prone  to  gangrenous 
destruction. 

The  constituent  elements  of  gangrenous  texture-masses  are,  more  or 
less  well-preserved  textural  de'bris,  larger  or  smaller  black-contoured 
molecules  down  to  a  pulverulent  granule  mass,  black  and  brown  pigment 
granules,  fat-drops  and  crystals,  saline  crystals. 

Contact,  reciprocity  of  action,  with  the  atmosphere,  is  by  no  means 
indispensable  to  the  generation  of  gangrene.  It  affects  equally  with 
the  external  parts,  organs  never  in  contact  with  the  air,  as  the  liver  and 
the  spleen. 


132  INFLAMMATORY    TEXTURES. 

A  very  important  phenomenon  involving  a  curative  act,  is  the  circum- 
scription of  gangrene  by  an  inflammatory  process  of  ulceration, — isola- 
tion of  the  gangrenous  part  through  its  own  secretion.  The  ultimate 
healing  is  brought  about  by  the  same  inflammatory  process  changing  to 
one  of  pus-production,  and  of  regeneration. 

CHARACTERISTIC   OF   INFLAMMATORY   TEXTURES  AND    DIAGNOSIS    OF 
INFLAMMATION    IN   THE   DEAD    SUBJECT. 

In  the  period  preceding  the  real  exudation,  an  organ  is,  within  the 
range  of  the  inflammation,  reddened,  injected ;  that  is,  more  than  ordi- 
narily vascular,  swollen,  and  at  the  same  time  relaxed,  softer,  lacerable. 
The  redness  must  be  that  of  injection,  and  is  to  be  carefully  discrimi- 
nated from  redness  of  imbibition.  The  swelling  and  relaxation  result 
from  infiltration  of  the  texture  with  exuded  blood-serum. 

Generally  speaking,  the  swelling  is  accompanied  by  increase  of  volume ; 
to  this,  however,  spongy  textures,  and  in  particular  the  lungs,  are  excep- 
tions. In  protracted,  and  especially  in  hypostatic  stases,  the  swelling 
of  the  texture  frequently  occasions  closure  of  the  pulmonary  cells,  and 
renders  them  inaccessible  to  atmospherical  air.  The  volume  of  the  in- 
flamed part  falls  short  of  the  normal. 

As,  however,  mere  hyperaemia  occasions  similar  appearances,  although 
in  a  minor  degree,  the  question  arises  :  "  What  are  the  criteria  in  the 
dead  body  which  justify  us  in  pronouncing  the  inflammatory  stasis  to 
be  attained  ?" 

The  only  true  criterion  in  the  dead  subject  is  afforded  in  the  changes 
suffered  by  the  blood  in  the  capillaries  of  the  implicated  texture,  during 
the  inflammatory  stasis — changes  cognizable,  in  part,  by  the  naked  eye. 

Effusion  having  taken  place,  its  product,  exudate.  affords  incontestable 
evidence  of  inflammation,  wherever  its  character  is  such  as  we  know  by 
experience  to  attach  solely  to  the  fruits  of  this  process ;  examples  are 
pus  or  croupous  fibrin.  The  redness  and  injection  cannot  here  com- 
monly apply,  having,  for  the  most  part,  given  way  to  the  effusion. 
Even  the  swollen  condition  of  the  texture  may  in  a  great  measure  have 
subsided  during  a  mortal  collapse.  The  relaxation  of  the  tissues  still 
lasts,  taking,  however,  in  solid  exudates,  the  form  rather  of  fragility,  as, 
for  instance,  in  the  hepatized  lung. 

Where,  however,  the  exudate  is  a  blastema,  well  known  to  exude  both 
with  and  without  inflammation,  the  question  arises  :  what  circumstances 
warrant  us  in  assuming  such  blastema  to  be  the  product  of  inflamma- 
tion ?  Such  circumstances  are — 

(a.)  Rapid  and  copious  production  of  the  blastema  ; 

(6.)  The  concurrence  of  exudates,  known  to  be  exclusively  generated 
by  inflammatory  stasis ; 

(c.)  Analogy  of  textural  destruction  with  that  due  to  inflammatory 
exudation,  more  especially  if  coupled  with  analogy  between  the  exudate 
and  a  product  pertaining  exclusively  to  inflammation,  as  between  tuber- 
culous infiltration  of  the  lung  and  hepatization,  and  again  between  the 
hepatizing  tubercle  and  the  fibrino-croupous  exudate. 

Lastly,  it  is  important  to  decide  whether  the  appearances,  in  the 


COROLLARY.  133 

neighborhood  of  a  product,  are  residue  of  the  inflammation  that  called 
it  forth,  or  the  rudiments  of  a  new  consecutive  inflammation  caused  by 
the  said  product.  The  discrimination,  so  far  as  it  is  feasible  at  all,  may 
be  deduced  from  what  has  been  already  stated. 

COROLLARY. 

(1.)  The  inflammatory  process  is  especially  fitted  for  displaying  the 
primitive  differences  of  blastemata,  those  inherent  properties  contingent 
upon  internal  (endogenous)  formative  processes. 

(2.)  It  is  equally  adapted  to  demonstrate  the  commonly  mixed  charac- 
ter of  blastemata,  and  the  consequent  variety  of  elementary  constituents 
which  enter  into  the  composition  of  a  new  growth. 

(3.)  It  is  the  last  of  a  series  of  exudative  processes,  beginning  with 
the  exudation  of  plasma  in  the  act  of  nutrition,  which  in  degree  and 
kind  probably  all  bear  more  or  less  resemblance  to  it. 

(4.)  Scarcely  a  new  growth  exists,  the  blastema  of  which  may  not  be 
produced  by  inflammation.  On  the  other  hand,  inflammation  yields 
products  proper  to  itself  alone.  It  is  to  be  observed,  at  the  same  time, 
that  where  a  corresponding  crasis  prevails,  the  stasis  requisite  for  the 
formation  of  the  product  is  in  the  inverse  ratio  of  the  intensity  of  the 
dyscrasial  process  in  the  general  circulation.  Such  exudatory  acts, 
together  with  other  processes  to  be  discussed  in  the  next  chapter,  are 
wont,  owing  to  the  rapidity  of  the  effusion  and  to  the  slightness  of  the 
accompanying  stasis,  to  be  characterized  as  deposits. 

(5.)  The  homceoplastic  textures  produced  by  inflammation  are  areolar 
tissue,  a  fibre  analogous  to  that  of  organic  muscle,  transition-cartilage, 
bone,  blood,  and  bloodvessels.  The  regeneration  of  nerve-fibrils,  after 
wounds  attended  with  loss  of  substance,  does  not  take  place  as  a  new 
formation  out  of  the  exudate,  but  as  growth  of  the  nerve  from  its  cut 
ends  into  the  exudate,  constituting  a  provisional  cicatrix. 

(6.)  Inflammation  possesses  now  a  local,  now  a  general  import.  In 
the  latter  case  it  is  the  localization  of  an  anomalous  crasis  which  stands 
to  it  in  the  relation  of  cause. 

(7.)  Inflammation  may  concur  with  a  crasis  either  accidentally  or  as 
its  symptom.  This  has  been  to  a  certain  extent  recognized  by  the 
acceptation  of  an  arthritic,  a  scrofulous,  a  scorbutic  inflammation. 
Custom  has  stamped  inflammation  with  fibrinous  exudates  and  a  kindred 
phlogistic  crasis,  as  genuine  inflammation. 

(8.)  How  ought  we  to  estimate  that  view  which  designates  inflamma- 
tion as  augmented,  vital,  and  formative  energy — as  increased  vascular 
activity, — as  reaction  ? 

Neither  in  the  sense  of  a  neuro-pathological  nor  of  an  attraction- 
theory,  can  there  be  any  question  of  increased  vascular  activity.  A 
vigorous  formative  power  no  doubt  is  at  work  in  the  inflammatory  pro- 
cess ;  still,  in  the  formative  efforts,  the  qualitative  anomaly  is  predomi- 
nant. Even  adhesive  inflammation,  in  which  one  might  be  most  of  all 
disposed  to  look  for  an  augmentation  of  the  normal  process  of  nutrition, 
produces  but  few,  and  these  simple,  textures. 

To  define  inflammation  as  a  reaction  of  the  organism  against  a  mor- 


134  DEPOSITS  —  METASTASIS. 

bific  influence,  is  simply  begging  the  question.  Inflammation  is  a  morbid 
process,  unconscious  of  its  scope  or  object,  evoked  by  a  causal  impulse, 
and  sustained  or  repeated  so  long  as  this  impulse  remains  in  activity. 
Only  in  this  general  sense  of  cause  and  effect  is  the  definition  of  re- 
action admissible. 

DEPOSITS. — METASTASIS  (SO-CALLED). 

Together  with  those  inflammations  leading  rapidly  and  insensibly  to 
exudation,  the  term  deposit  (metastasis,  capillary  phlebitis,  lobular 
process)  applies  aptly  to  certain  processes  which,  considering  the  rapi- 
dity with  which  they  become  established,  are,  in  many  respects,  of  a 
very  remarkable  kind.  These  processes  are  founded  in  a  sickening  of 
the  fibrin,  with  a  tendency  to  coagulation.  They  consist  in  the  blood, 
through  spontaneous  impairment  or  through  infection  [that  is,  the 
reception  of  various  substances],  acquiring  the  tendency  to  coagulate, 
and  actually  coagulating  within  the  circulating  system,  under  a  more  or 
less  marked  separation  of  fibrin. 

This  happens  either  in  one  of  the  larger  vessels,  or,  what  is  far  more 
common,  in  the  capillaries  of  an  organ.  In  the  former  case  it  is,  con- 
sistently with  the  frequent  reception  of  deleterious  substances  into  the 
venous  blood,  the  larger  veins,  usually  in  the  vicinity  of  the  point  of 
infection.  With  respect  to  the  capillary  system,  no  point  of  it  is 
exempt,  although  the  more  vascular  organs,  those  in  which  the  blood 
undergoes  important  changes,  are  most  obnoxious  to  the  affection ;  for 
example,  the  lungs,  the  spleen,  the  kidneys. 

In  large  vessels  it  is  not  difficult  to  interpret  the  appearances.  In 
the  absence  of  all  evidence  of  local  inflammation  of  the  vessel's  coats, 
the  calibre  is  plugged  with  lengthy,  cylindrical,  or  smaller,  clod-like — 
in  vascular  trunks  membranaceous, — in  arteries,  especially  where  the 
inner  surface  is  rough  or  gibbous,  adherent — coagula.  The  probability 
of  these  coagula  resulting  from  inflammation  of  the  vessels,  increases  in 
proportion  as  the  fibrin  which  constitutes  them  is  pure,  and  as  its  yellow 
color  and  general  attributes  approximate  to  those  of  croupous  fibrin. 
The  various  coagula  found  within  the  heart's  cavities — the  valvular,  the 
globular,  vegetations,  belong  to  the  same  class. 

The  cylindrical  and  clod-like  coagula  are  often  equably  reddened  by 
incorporated  blood-corpuscles.  At  other  times  they  contain  layers  of  a 
lighter  color  than  the  rest,  and  which  therefore  have  incorporated  fewer 
blood-corpuscles.  Some  layers  are  even  marked  by  a  total  absence  of 
redness,  and  obviously  consist  of  pure  effused  fibrin. 

To  trace  the  process  in  the  capillaries  is  not  an  easy  matter.  It  is 
conceivable  that  besides  what  happens  within  the  vessels,  and  as  a  con- 
sequence thereof,  exudation  of  blood-serum,  and  even  of  a  portion  of 
plasma  with  blood-pigment  takes  place.  By  means  of  this  exudation, 
the  vessels  become  obscured  and  uncognizable.  Still,  the  simple  fact  of 
the  process  occurring  in  large  vessels  should  remove  all  doubt  as  to  its 
existence  in  the  capillaries. 

In  the  capillaries  of  an  organ,  the  process  originally  manifests  itself 


DEPOSITS METASTASIS.  135 

by  a  dark  red,  sometimes  reddish-white,  spangled  or  striated,  circum- 
scribed, impacted  substance,  of  a  dense,  fragile  consistence. 

These  impactions  possess  the  peculiarity  of  being  seated  for  the  most 
part  in  the  periphery  of  organs, — the  lungs,  spleen,  kidneys,  for 
instance.  They  represent  roundish  tubercula  or  else  wedges  with  their 
broad  base  directed  towards  the  periphery  and  impinging  upon  the 
sheath, — their  points  towards  the  interior  of  the  organ.  They  are 
always  present  in  considerable  number,  and  commonly  associated  with 
exudative  processes.  Their  size  is  mostly  inconsiderable,  commonly 
ranging  from  that  of  a  pea  to  that  of  a  walnut.  In  organs  of  a  lobu- 
lated  structure,  they  are  sometimes  called  lobular  metastases. 

The  ulterior  changes  are  various,  corresponding  with  the  nature  of 
the  coagulation,  and  therefore  of  the  blood-(fibrin)  disease. 

They  sometimes  shrivel  and  condense,  with  obliteration  of  the  canals 
of  the  vessels,  and  of  the  implicated  textures,  into  a  fibroid  state, — 
still  further  shrivelling  callus,  towards  which  the  neighboring  parts  are 
retracted  in  a  scar-like  manner,  and  which  often  involves  a  residue  of 
blood-pigment  in  the  shape  of  rusty  brown,  or  rusty  yellow  coloration. 

It  is  probable  that,  like  the  thrombus,  they  are  often  progressively 
redissolved,  and  again  taken  up  into  the  circulation  without  detriment 
to  the  textures. 

Sometimes  they  break  down  to  a  puriform,  ichorous  fluid,  to  gangre- 
nous ichor,  with  diffluence  and  necrosis  of  the  involved  textures,  result- 
ing in  a  pus  or  ichor  dep6t,  or  a  gangrenous  slough.  In  greater  coagula, 
this  metamorphosis  very  commonly  emanates  from  the  central  layer. 
Capillary  impactions,  at  the  periphery  of  an  organ,  often  assume  the 
aspect  of  a  superficial  boil. 

The  coagula  often  undergo  fatty  conversion. 

Occasionally,  the  coagula  have  the  character  of  tubercle  or  of  cancer, 
especially  of  medullary  cancer  ;  and  it  is  probably  through  this  process 
that  the  often  very  rapid  development  of  cancer  is  produced  in  brutes, 
by  the  injection  of  cancer-blastema. 

In  conclusion,  many  an  important  crase-exhausting  metastasis  may 
have  its  source  in  the  same  processes,  involving  a  great  extent  of  capil- 
laries, and  issuing  in  gangrene.  Such  metastases  occur  as  the  sequel  to 
typhus,  and  to  the  exanthemata. 

With  respect  to  the  organs  whose  capillaries  are  especially  obnoxious 
to  these  coagula  resulting  from  infection  of  the  blood,  as  it  is  in  venous 
blood  that  the  mischief  commonly  originates,  and  as  the  lungs  are  the 
first  organs  reached  by  the  poison,  their  capillary  tissue  is  commonly 
the  first  to  suffer.  In  its  arterial  passage,  the  contaminated  blood  next 
attacks  the  capillaries  of  the  spleen,  and  of  the  kidneys.  Lastly,  in  a 
higher  grade  of  the  dyscrasis,  all  the  other  textures,  mucous  mem- 
branes, common  integuments,  and  subcutaneous  areolar  tissue,  even 
bone,  become  implicated  in  their  turn. 

In  infection  of  the  portal  blood,  the  liver  is  the  first  assailed,  other- 
wise it  is  only  so  in  common  with  other  organs,  and  by  no  means  more 
frequently  than  the  spleen  and  kidneys. 

That,  compared  with  the  greater  vessels,  and  especially  the  arteries, 
these  processes  occur  pre-eminently  in  the  capillary  system,  seems  due 


136  ORGANIZED    NEW    GROWTHS. 

to  the  slackening  of  the  circulation  in  the  capillaries,  which  in  itself 
promotes  coagulation,  and  at  the  same  time,  leaves  the  deleterious 
matter  longer  in  contact  with  the  blood.  In  certain  organs,  moreover, 
their  formation  appears,  as  before  stated,  to  be  favored  by  the  revulsion 
which  the  blood  undergoes  in  them  during  the  acts  of  nutrition  and 
secretion. 

Sensitive  as  is  arterial  blood  in  respect  to  infection,  as  in  arteries,  for 
instance,  coagula  are  comparatively  rare  in  arteries  of  the  aortal 
system,  with  the  exception  of  those  at  the  point  of  arterial  inflam- 
mation. This  is  probably  owing  to  the  great  rapidity  of  the  arterial 
current.  In  the  arterial  section  of  the  heart,  however,  they  are  readily 
engendered  by  diminished  action  of  their  organ,  far  more  readily  than 
out  of  the  venous  blood  in  its  right  chambers. 

The  relation  which  these  processes  bear  to  inflammation  and  its 
terminations,  is  obvious.  Determined  by  high  grades  of  dyscrasial 
impairment  of  the  blood,  they  represent  product  formation,  endogenous 
exudation,  within  the  vascular  system. 


B.  ORGANIZED  NEW  GROWTHS  SPECIALLY  CONSIDERED. 

Having  now  treated  of  organized  *new  growths  in  general,  of  their 
blastemata,  and  of  the  several  processes  through  which  these  are  engen- 
dered, we  come  to  the  special  consideration  of  new  growths. 

What  order  ought  we  to  observe  in  this  discussion  ? 

(1.)  An  arrangement  based  upon  morphological  relations  is  inadmis- 
sible : 

(a.)  The  elements  being  in  themselves  far  too  uniform,  in  their  secon- 
dary arrangement  too  multiform,  and  generally  too  little  distinctive  of 
the  nature  of  the  new  growth. 

(6.)  The  elements  being  mutable,  what  is  one  day  in  the  embryonic 
state,  is  found  further  advanced  on  the  morrow  ;  whilst  various  grades 
of  development  are  found  to  co-exist  in  juxtaposition. 

(2.)  Similar  objections  obtain  against  a  division  of  new  growths 
according  to  their  main  organico-chemical  constituents ;  these  being  not 
alone  convertible  substances,  but  also  liable  to  enter  into  various  combi- 
nations in  the  same  growth. 

(3.)  With  respect  to  the  distinction  of  new  growths  into  homoeoplasiae 
and  heteroplasise,  we  have  already  once  expressed  an  opinion.  A  sys- 
tematic arrangement  upon  such  a  basis,  irrespectively  of  its  preternatural 
rigor,  is  open  to  the  objection,  that  it  breaks  up  new  growths  into  two 
great  series,  in  the  first  of  which  no  doubt  many  points  offer  in  the  ana- 
logies for  further  subdivision.  In  the  second,  however,  we  are  either 
driven  to  a  ground  of  distinction  alien  to  the  system,  er  else  compelled, 
in  opposition  to  the  principle  itself,  still  to  have  recourse  to  comparison 
with  normal  textures. 

(4.)  How  little  the  benign  or  malignant  nature  of  new  growths  in 
general,  affords  a  basis  for  a  genuine  classification  is  self-evident. 

In  order  to  avoid  the  difficulties  alluded  to,  we  shall  here  endeavor  to 
observe  a  middle  path,  and  treat  of  new  growths  in  a  series  beginning 


AREOLAR    TISSUE    FORMATIONS.  137 

with  those  which  bear  the  evident  tokens  of  benignancy,  and  whose 
ulterior  development  is  for  the  most  part  one  of  progress  into  fibre ; 
passing  next  to  those  differently  constituted  in  these  particulars. 


1.   AREOLAR   TISSUE   FORMATIONS. 

The  new  growth  of  areolar  tissue  is  a  very  widely  extended  one. 
Newly  generated  areolar  tissue  occurs  both  pure,  and  also  as  a  con- 
stituent of  other  new  formations,  for  which  it  often  furnishes  a  sort 
of  stroma  or  framework.  Generally  speaking,  it  is  not  alone  as  to  the 
constitution  of,  but  also  as  to  the  arrangement  of  its  fibres  in  new  growths, 
a  repetition  of  the  normal.  In  the  said  stroma  or  framework,  however, 
of  many  cancerous  growths,  there  occur  fibrils  of  extraordinary  deli- 
cacy. 

Its  development  often  follows  the  laws  of  the  cell-theory,  that  is 
nucleus,  cell-formation,  spindle-shaped,  caudate  cell,  fibre  with  attached 
nucleus,  fusion  of  several  cells  to  a  varicose  fibre,  breaking  up  of  the 
fibres  into  fibrils.  Areolar  tissue  is,  however,  much  more  frequently  and 
more  extensively  shaped  out  of  the  immediate  dissilience  of  a  solid 
blastema  into  areolar  tissue  fibre,  or  else  mediately,  through  a  prelimi- 
nary splitting  into  other  coarser  fibres. 

Newly  formed  areolar  tissue  is  often  found  blended  in  different  pro- 
portions with  elastic  fibres,  nucleus  fibres  in  various  degrees  of  develop- 
ment, from  the  oblong,  caudate  nucleus,  the  rodlike  fibre  stem,  to  the 
complete  fibre. 

Apart  from  its  occurrence  as  mere  increment  of  that  previously  ex- 
isting (hypertrophy) — areolar  tissue  of  new  formation  is  met  with : 

(a.)  In  the  shape  of  threaden,  cord-like  growths,  of  flocculent  and 
velvety  accumulations,  of  either  free,  bridle-like,  or  agglutinated  and 
firmly  seated  layers  and  membranes  upon  serous  tunics,  even  of  entirely 
new-formed,  movable,  serous  sacs.  In  many  such  cases  it  is,  as  mem- 
brane, invested  with  an  epithelium  on  its  inner  free  surface. 

It  determines  those  frequent  adhesions  of  organs  contained  within 
serous  sacs,  both  with  each  other,  and  with  the  parietes  of  the  latter. 

S1).)  It  constitutes  the  entire  parietes  of  perfectly  new  anomalous  serous 
synovial  sacs,  or  else  it  partially  enters  into  their  composition  for 
the  most  part  as  the  external  layer,  in  connection  with  fibroid  textures. 
To  this  class  belong  the  anomalous  bursse  mucosse,  the  articular  capsules 
of  preternatural  joints,  the  capsules  investing  foreign  bodies  or  extrava- 
sate  (the  envelopes  of  apoplectic  cysts),  every  variety  of  cyst-formation. 

(c.)  It  forms  the  external  vascular  sheath  of  many  new  growths,  both 
benign  and  malignant,  fibroid  and  cancerous,  or  their  stroma,  for  example 
in  lipoma. 

(rf.)  Of  tumors  it  forms  the  condyloma,  the  hypertrophous  lupus,  the 
pedunculated  wart.  Commonly  conjoined  with  fatty  texture,  it  com- 
poses those  appendices  of  the  skin  denominated  moUusca,  a  species  of 
so-called  fibrous  tumors  and  of  fibrous  polypi. 

(e.)  Finally  it  presents  in  various  grades  of  development  an  essential 
constituent  of  scar-texture. 


138  FIBROID    TEXTURE. 

The  growths  composed  of  it  contain  a  large  proportion  of  gluten. 

The  blastema  for  the  new  growth  of  areolar  tissue  is  sometimes  fluid, 
and  the  development  takes  place  according  to  the  call-theory  laws,  but 
more  often,  especially  when  copious,  it  is  solid  and  fibrinous.  It  exudes 
during  the  progress  of  protracted  hyperaemiae,  and  in  the  last-mentioned 
form,  more  especially,  as  a  consequence  of  inflammatory  stasis.  Both 
modes  of  development  concur  with  suppuration.  Moreover,  extravasated 
fibrin,  as  also  endogenous  fibrin-coagula  within  the  vessels  furnish,  under 
certain  conditions  of  the  fibrin,  the  blastema  for  the  new  formation  of 
areolar  tissue. 

The  chemical  changes  which  take  place  during  this  process  of  develop- 
ment are  very  remarkable.  They  consist  in  numerous  modifications  of 
quantitative  type,  as  also  in  qualitative  differences  of  reaction  observable 
in  the  gluten-extracts. 

The  time  requisite  for  the  new  growth  of  areolar  tissue  varies  from  one 
to  several  weeks.  The  process  of  dissilience  into  areolar  tissue  fibres 
and  fibrils,  more  especially  in  the  case  of  copious  solid  blastemata,  is 
often  a  very  slow  one. 

2.   FIBROID   TEXTURE. 

In  an  extended  sense,  the  collective  term  fibroid  texture  may  be  made 
to  comprise  all  fibrous  tissues,  the  development  of  which  has  been  already 
delineated,  and  the  occurrence  of  which  as  a  more  or  less  essential  com- 
ponent of  various  new  growths,  it  becomes  our  business  to  discuss. 

Nowhere  is  the  insufficiency  of  a  mere  anatomical  principle  more  felt 
than  here — a  principle  which  would  needs  occasion  us  to  class  side  by 
side,  the  most  heterogeneous  new  growths,  for  example,  fibro-carcinoma 
and  the  perfectly  benign  fibroid  tumor. 

In  a  more  restricted  sense  we  comprehend  under  fibroid  textures  those 
which  consist  either  of  the  elements  about  to  be  described  or  of  a  blastema 
manifestly  furnishing  their  groundwork,  which  yield  gluten,  are  benign, 
and  in  external  appearance,  resemble  the"  fibrous  texture.  In  this  sense 
the  fibroid  texture  enters  into  the  composition  of  various  heterologous 
growths,  constituting  in  them  the  benign  ingredient  which  cornifies  or 
ossifies  by  a  spontaneous  metamorphosis.  Or  it  is  woven  in  with  normal 
textures,  or,  lastly,  it  represents  sharply  defined,  often  very  voluminous 
masses,  in  a  word,  tumors.  The  fibroid  (fibrous)  tumor,  besides  the 
aforesaid  attributes,  is  distinguished  as  consisting  entirely  or  almost 
entirely  of  the  elements  of  the  fibroid  texture.  It  is  firm  and  elastic,  or 
else  tough,  presenting  a  mere  local  evil,  independent  of  dyscrasial  taint 
and  originating  in  local  deposition,  a  fact  denoted  more  especially  by  its 
selection  of  a  particular  organ,  even  where  it  occurs  in  great  numbers. 

The  groundwork  of  fibroid  new  growths  are  firm,  probably  always 
fibrinous  blastemata.  Exudation  or  extravasation-fibrin,  or  fibrinous 
coagula  within  bloodvessels  often  constitute  these. 

Irrespectively  of  perfected  areolar-tissue  fibre,  as  the  main,  if  not  the 
sole  constituent  of  growths  called,  from  their  dense  texture  and  their 
resistance,  fibro-areolar  textures,  or  fibrous  tumors, — the  following  ele- 
ments are  in  particular  deserving  of  notice. 


FIBROID    TEXTURE.  139 

(a.)  Flat,  smooth  fibres  resembling  the  organic  muscle-fibre,  here  and 
there  breaking  up  into  fibrils,  and  thus  engaged  in  the  transition  to 
areolar  tissue.  The  nuclei  present  deport  themselves  as  upon  muscle- 
fibre,  and  the  textures  proper  to  it. 

(b.)  Flat,  broad,  band-like  or  roundish,  shapeless,  solid  fibres,  with 
rough,  denticulatad  or  felt-like  outline,  which  are  held  together  by  a 
solid  blastema,  and  here  and  there  break  up  into  areolar-tissue  fibrils. 
Nuclei  often  seem  to  stand  in  no  developmental  relation  to  them,  and  are 
frequently  altogether  absent. 

(c.)  The  fibroid  blastema,  an  embryonic,  stratiform,  fibro-laminated, 
solid,  transparent,  or  opaque  (brawn-like),  formation,  interspersed,  or  not 
interspersed,  with  elementary  granules,  nuclei,  and  cells. 

The  delicate  fibre  network  of  solidified  fibrin  is  occasionally  preserved 
in  it. 

The  above-named  fibre-elements  originate  directly  out  of  their  blastema 
through  dissilience.  The  formations  consisting  of  them  occur  both  as 
superficial  expansions,  and  interwoven  in  normal  textures,  as  knotted, 
spherical,  or  irregularly  ramified  masses  (callosities) ;  and,  lastly,  as  inde- 
pendent tumors. 

These  various  formations  demand  a  special  inquiry.  Besides  the  true 
fibrous  tumors,  of  which  we  shall  have  to  treat  specially,  we  have  here 
to  mention : 

Inflammatory  products,  fibroid  exudates,  representing  within  paren- 
chymata,  irregularly  knotted,  ramified  masses,  or,  upon  serous  mem- 
branes, superficial  expansions.  The  latter  constitute  pseudo-membranous 
calli  of  various  dimensions,  but  frequently  engrossing  the  entire  super- 
ficies of  a  serous  sac.  They  are  of  various  thickness,  which  is  considera- 
ble upon  the  parietal  layer  of  serous  sacs,  of  density  and  resistance  equal 
to  those  of  fibro-cartilage ;  in  color  white,  or  as  a  consequence  of  hemor- 
rhagic  exudation,  varied  with  black,  slate-gray,  rust-brown,  or  a  yeast- 
yellow.  They  often  determine  complete  conglutination  of  the  parietal 
and  visceral  layers  of  serous  sacs.  Or,  again,  they  are  smooth  and  even, 
or  fenestrated,  granular,  stellate  plates ;  or  finally,  they  consist  of  granu- 
lations, scarcely  surpassing  in  size,  poppy,  millet,  and  hemp  seeds,  for 
example,  upon  the  cerebral  arachnoid  membrane,  upon  the  hepatic  and 
splenic  peritoneum,  &c. 

The  fibroid  thickening  of  serous  membranes  in  the  shape  of  smooth  or 
granulated  plates,  of  granulations,  to  which  last  are  to  be  reckoned  the 
Pacchionian  glands. 

Most  free  bodies  found  within  serous  and  synovial  sacs. 

Cicatrix-substance  generally,  as  also  the  so-termed  keloid  of  Alibert — 
arrested  (ligarnentous)  callus. 

The  internal  layers  of  numerous  cysts  and  of  receptacles  and  excretory 
ducts  degenerated  into  dropsical  capsules  (dropsy  of  the  gall-bladder ; 
of  the  Fallopian  tube). 

Callosed  extravasate-fibrin,  in  shape  of  central  or  peripheral  (encyst- 
ing) membrane  separated  out  of  extravasates. 

Callosed  coagulations  of  fibrin  within  the  vascular  system,  the  different 
so-called  vegetations  in  the  heart's  cavities,  the  cylindrical  coagula 
within  veins  and  arteries. 


140  FIBROID    TEXTURE. 

The  superimposed  layers  upon  the  internal  surface  of  arteries ;  the 
soft  groundwork  of  so-called  phlebolites  ;  &c. 

These  fibroid  formations  not  unfrequently  inclose  within  a  nidus,  a 
curd-like  or  puriform  fibrin — the  product  of  inflammation. 

The  secondary  arrangement  of  the  elements  above  treated  of,  is  redu- 
cible to  the  following  types : 

1.  Parallel  fibrillation,  superficial  expansion  predominating. 

2.  Fibre-felt,  a  multicrucial  fibrillation,  a  section  of  which,  in  what- 
ever direction  made,  always  displays  fibre-shoots  and  bundles,  intersect- 
ing each  other  at  various  angles. 

3.  Areolar  disposition,  of  very  rare  occurrence,  at  least  in  pure  fibroid 
formations  springing  from  a  solid  blastema. 

The  two  following  structures,  determined  by  a  primitive  disposition  of 
the  coagulating  process,  are  also  rare. 

4.  A  network  of  fibroid  bridles  (fibre  bundles),  of  from  ^th  to  y^th 
of  a  millimetre  broad,  crossing  each  other  at  various  angles,  and  having 
their  gaps  filled  up  with  embryonic  elements — for  the  most  part  nucleus- 
formations  in  an  amorphous  blastema. 

5.  A  web  of  similar  fibroid  cords  emanating  from  a  central  mass,  and 
anastomosing  with  other  webs  derived  from  other  centres. 

These  structures  seem  to  occur  more  especially  in  fibroid  formations 
springing  from  extravasate-fibrin,  as%  occasionally  met  with  in  stratified 
deposits  upon  the  inner  surface  of  arteries. 

6.  Finally,  a  kindred  form  is  brought  about  by  resorption,  as  a  gap 
or  fenestrate-formation,   the  gaps  being  round  or  oval.     It  occurs  in 
fibroid  tumors,  in  the  fibroid  thrombus,  in   the  vegetations  within  the 
heart's  cavities,  but  especially  in  the  accumulated  layers  upon  the  in- 
ternal arterial  membrane.     It  is  analogous  with  the  fenestrated  structure 
of  the  striated  coat  of  bloodvessels. 

All  these  formations  have,  even  for  the  naked  eye,  the  aspect  of  a 
porous,  cancellated  structure ;  the  gaps  are,  however,  widely  different 
from  the  alveoli  of  areolar  textures. 

(d.)  A  further  element  of  fibroid  formations  is  a  cylindrical,  in  its 
parietes  structureless,  striated  fibre,  with  a  simple,  but  sometimes  a 
double  contour,  inclosing  granules,  nuclei  and  cells.  We  have  encoun- 
tered this  sort  of  fibre  in  consolidated  hemorrhagic  effusion ;  in  old 
vegetations  about  the  heart's  valves  ;  in  fibred  cartilaginous  investments 
of  the  joints ;  in  the  villous  new  growths  upon  synovial  capsules. 

(e.)  Another  element,  again,  of  fibroid  growths  is  the  nucleus  and  the 
nucleus-fibre  in  the  intermediate  stages,  as  caudate  nucleus,  and  varicose 
nucleus-fibre.  These  elements  are  to  a  certain  extent  found  in  conjunc- 
tion with  those  hitherto  discussed,  with  the  concurrence,  however,  of  an 
amorphous  bond-substance — a  membranous  basement.  They  extensively 
furnish  forth  fibroid  growths,  but  are  not  very  common. 

(/.)  To  conclude,  not  a  few  fibroid  new  growths  consist  in  a  fibre-felt, 
developed  within  a  basement  either  solid  or  adapted  for  membranous  ex- 
pansion. It  resembles  that  in  the  intercellular  substance  of  reticular 
cartilage.  This  texture  is  often  met  with  in  the  fibroid  deposits  within 
arteries. 

A  metamorphosis  common  to  fibroid  textures,  is  a  so-called  ossifica- 


FIBROID    TEXTURE.  141 

tion,  and  a  cornification.  The  former  is  observed  more  especially  in 
fibroid  tumors,  in  fibroid  exudates,  upon  serous  membranes,  in  fibrinous 
coagula  within  the  calibre  of  bloodvessels,  in  the  deposits  upon  the  inner 
membrane  of  arteries,  and  the  like.  The  growth  shrivels  with  oblitera- 
tion of  its  vessels,  loses  its  elasticity,  becomes  dry,  of  a  dingy  yellow 
color,  and  gradually  bereft  of  its  fibrous  texture.  Meanwhile  a  black, 
minute  molecule,  consisting  of  fat  with  the  salts  of  lime,  becomes 
imbedded  in  its  substance. 

Cornification  is  observed  especially  in  the  vegetations  about  the  heart's 
valves,  and  in  the  layers  accumulated  within  arteries.  The  growth  be- 
comes dry,  denser,  of  horn-like  toughness,  and  of  dull  transparency. 

Vascularized  fibroid  growths  occasionally  take  on  inflammation,  for 
the  most  part  from  the  surrounding  tissues,  suppurate,  and  perish  layer 
by  layer.  Nor  is  it  rare  for  them  to  become  loosened  and  cast  away 
through  the  suppuration  of  adjoining  textures. 

Crluten  yielding  fibroid  tumor,  also  denominated  fibrous  tumor,  for- 
merly designated  as  sarcoma,  steatoma,  or  even  as  scirrhus. 

They  are  distinguished  from  other  fibroid  tumors  by  their  indepen- 
dence and  circumscription,  as  being  sheathed  in  a  layer  of  vascular  and 
areolar  tissue,  and  thus,  as  it  were,  impacted  in  the  texture  of  organs, 
from  whence  they  may  be  fairly  peeled  out.  They  represent  more  or 
less  perfectly  spherical,  for  the  most  part  tough,  fibro-cartilage-like,  re- 
sisting, distinctly  fibrous,  according  to  their  degree  of  vascularity,  whitish 
or  reddish-white,  new  growths.  In  size  they  vary  from  that  of  a  tumor 
just  cognizable,  up  to,  and  beyond  that  of  a  man's  head.  They  often 
coexist  numerously  in  the  same  organ. 

They  probably  occur  in  every  organ,  although  they  are,  without 
doubt,  frequently  confounded,  more  especially  in  glands,  with  fibrous 
sarcoma,  and  with  fibro-carcmoma.  They  are  frequent  in  the  submu- 
cous  areolar  tissue  layers,  more  particularly  in  the  intestine,  stomach, 
and  oesophagus,  now  and  then  in  the  larynx,  again,  in  the  subcutaneous 
areolar  tissue,  and  very  commonly  in  the  uterus  and  its  appendages, 
where  their  development  is  in  every  way  very  strongly  marked.  Their 
texture  is  usually  made  up  of  areolar-tissue  fibre,  or  of  the  elements  de- 
scribed at  a,  b,  and  c.  The  uterus  fibroids,  in  particular,  very  often 
repeat  the  fibre  of  organic-muscle  tissue. 

With  respect  to  the  arrangement  of  the  constituting  fibres,  fibre- 
layers  and  fasciculi,  much  variety  is  manifested,  and  this,  again,  is  pre- 
eminently marked  in  the  uterus  fibroid.  Thus : 

(a.)  The  fibroid  tumor,  with  concentrical  lamination  of  the  fibre-layers, 
is  commonly  quite  spherical,  very  dense  and  tough,  poor  in  bloodvessels, 
white,  never  attaining  the  magnitude  of  the  species  that  follow. 

(6.)  Fibroid,  with  manifold  decussation  of  the  fibres.  The  fibration 
frequently  springs  from  distinct  centres  marked  by  their  density  and 
whiteness.  These  tumors  grow  to  a  considerable  magnitude,  and  have 
an  irregular  flattened  tuberosity  of  surface. 

The  following  is  a  variety  of  this  fibroid : 

The  tumor  consists  of  an  aggregation  of  dense  fibroid  tubercula  or 
centres,  about  the  size  of  peas  or  beans,  united  by  means  of  a  lax 
vascular  texture.  These  tumors  have  an  uneven  undulating  surface,  and 


142  ELASTIC    TISSUE. 

attain  to  a  very  considerable  bulk.  The  loose  interstitial  texture  some- 
times becomes  the  seat  of  a  serous  infiltration,  which,  under  dragging 
and  eventual  laceration  of  the  said  texture,  may  become  exalted  into 
dropsy  within  the  tumor.  The  fibroid  contains  within  its  interior  a 
cavity  replete  with  serous  fluid,  fluctuates,  and  may  thus  present  the  ap- 
pearances of  a  cyst — in  the  uterus,  more  particularly  that  of  a  hydro- 
metra. 

All  these  fibroids  ossify. 

(c.)  There  is  one  other  variety  of  fibre-tumor,  which,  so  far  as  its  ele- 
ments are  concerned,  ranks  with  the  foregoing  growths.  In  other 
respects,  however,  it  differs  from  them,  and  offers  a  transition  form  to 
fibro-sarcoma. 

The  characteristic  of  this  last  form  of  fibrous  tumors  is  that,  varying 
in  circumference,  they  are  so  rooted  in  the  implicated  organs  as  not  to 
be  removable  from,  without  injury  to,  the  latter ;  that  they  become 
lobulated  in  their  growth,  and  yield  little  gluten ;  whilst,  on  the  other 
hand,  they  contain  albumen,  and  in  their  fibrillation  are,  at  least  in  part, 
developed  out  of  cells.  Not  rarely  we  find  in  them  excavations  lined 
with  a  smooth  membrane,  and  filled  with  a  sere-albuminous  fluid,  alveoli, 
cysts.  They  are  further  marked  by  considerable  vascularity. 

Like  other  kindred  forms  referable  to  the  class  of  fibro-sarcoma,  they 
are  often  rooted  in  the  submucous,  ,areolar,  and  muscular  textures,  in 
areolar  tissue,  in  the  periosteum  subjacent  to  mucous  membranes,  and  in 
the  inner  layers  of  the  substance  of  the  womb.  Here,  under  the  designation 
of  fibrous,  sarcomatous  flesh-polypi,  they  grow  into  the  muco-membranous 
cavities,  with  predominant  longitudinal  direction  of  their  fibres,  pushing 
forward  the  mucous  membranes  themselves  in  their  advance,  and  repre- 
senting cylindrical,  spindle-like,  pear-shaped,  bulbous  tumors,  lobulated 
at  their  free  extremity,  and  traversed,  more  especially  in  the  uterus,  by 
capacious  bloodvessels  (veins). 

As  so-called  polypi,  they  are  to  be  carefully  distinguished  from 
mucous,  cellular,  or  vesicular  polypi. 

They  do  not  ossify. 

3.  ELASTIC   TISSUE   AND  TEXTURE   OF  THE  ANNULO-FIBROUS  MEMBRANE 

OF  ARTERIES. 

The  elastic  and  nucleus-fibres  enter,  more  or  less,  and  sometimes  in 
very  considerable  quantity,  into  the  composition  of  the  most  varied  new 
growths,  although  in  no  instance  are  the  latter  entirely  composed  of 
them. 

We  have,  however,  occasionally  observed  accumulations  of  elastic 
fibres,  in  the  arrangement  and  form  proper  to  the  vocal  chords,  beneath 
the  mucous  membrane  of  the  trachea,  and  close  to  the  larynx. 

With  reference  to  the  texture  of  the  annulo-fibrous  membrane,  we 
have,  in  one  instance,  seen  the  muscular  fibres  of  a  hypertrophied,  soli- 
dified, rigid,  muscular  tunic  of  the  urinary  bladder  converted  into  dingy 
yellow,  elastic  bands,  which  presented  a  texture  exactly  like  that  of  the 
annulo-fibrous  membrane  of  arteries.  A  transformation  of  one  texture- 
species,  pertaining  to  a  common  genus,  into  another. 


CARTILAGINOUS    GROWTHS.  143 

4.    CARTILAGINOUS  GROWTHS. 

Wounds  of  cartilage  are  not  reunited  by  means  of  cartilaginous  sub- 
stance, nor  is  this  substance  regenerated  when  destroyed.  Nevertheless 
new  growths  of  cartilage-texture  are  both  frequent  and  voluminous. 
The  structure  of  these  growths  or  tumors  was  first  ascertained,  with  the 
aid  of  the  microscope,  by  Johannes  Muller,  who  applied  to  them  the 
term  enchondroma.  These  excepted,  not  a  single  new  growth,  whether 
designated  as  cartilage-like,  fibro-cartilage-like,  or  as  cartilaginescence, 
chondroid,  fibro-chondroid,  has  more  than  a  seeming  analogy  with  true 
cartilage  texture. 

Enchondroma  repeats  all  the  special  physiological  textures  of  carti- 
lage. It  occurs  both  as  hyaline,  genuine,  as  fibro-cartilage,  and  as 
reticular  cartilage,  imitating  the  articular  investments,  the  laryngeal 
cartilages,  and  the  septum  narium  on  the  one  side,  and  the  synchondroses 
of  the  vertebrae,  the  cartilages  of  the  external  ear,  the  epiglottis,  &c.,  on 
the  other. 

Ordinarily,  and  especially  in  the  enchondroma  of  soft  parts,  all  these 
forms  are  often  found  in  juxtaposition.  The  pure  hyaline  cartilage  is, 
however,  the  least  common,  the  intercellular  substance  displaying,  for 
the  most  part,  a  fibrillation  similar  to  that  in  the  cartilages  of  the  ribs. 

The  enchondroma  forms  spherical,  or  nearly  spherical  tumors,  with 
an  even,  smooth,  or  else,  which  is  more  usual,  a  mammillated  surface. 
Internally  it  either  presents  a  continuous  hyaline  mass,  or  else,  corre- 
sponding with  its  mammillated  exterior,  a  lobulated  structure,  an  aggre- 
gate of  denser,  hyaline  knobs  or  spheres,  either  held  together  by  a  black- 
contoured,  rough,  inelastic  fibre  texture,  resembling  the  intercellular 
fibrillation,  or  else  imbedded  in  a  loose  texture  imitating  the  fibre-layer 
of  reticular  cartilage. 

Enchondroma  chiefly  occurs  in  bones,  especially  in  the  phalanges  of 
the  fingers  and  toes,  in  the  sternum,  in  the  ribs,  more  rarely  in  other 
bones,  such  as  the  long  cylindrical  bones,  the  ilium,  the  skull-bones.  It 
is  also  met  with  in  the  mammary  gland,  in  the  parotis,  in  the  testicle. 
We  have  ourselves  seen  it  in  the  subcutaneous  areolar  tissue,  and  on 
several  occasions  in  the  lungs. 

In  magnitude,  enchondroma  varies  from  that  of  a  tumor  only  just 
cognizable  to  that  of  a  child's  head,  and  beyond  it.  In  bone,  enchon- 
droma exhibits  two  varieties,  namely,  enchondroma  with  and  enchondroma 
without  bony  sheath.  This  osseous  capsule  is  bone,  whose  texture  has 
become  distended  and  inflated  by  the  enchondroma  in  the  progress  of  its 
upward  development.  In  this  process  it  has,  for  the  most  part,  increased 
in  substance,  so  that  the  capsule  far  exceeds,  in  this  respect,  the  original 
bone.  Where  the  sheath  ruptures  at  an  early  period,  the  enchondroma 
is  devoid  of  bony  investment.  The  capsular  case  of  the  enchondroma 
is  unessential,  and  is  common  to  many  other  heterologous  growths  de- 
veloped out  of  the  depth  of  bone,  and  more  especially  out  of  a  medullary 
cavity.  Many  of  the  so-termed  cases  of  spina  ventosa  of  older  observers, 
were  probably  of  the  nature  of  enchondroma. 

Enchondroma  is  benign,  provided  it  does  not  enter  into  any  specific, 
infectious  metamorphosis,  and  only  undergoes  ichorous  destruction  from 
irritation.  A  peculiar  predisposition  to  its  formation  does,  however, 


144  BONE-FORMATION. 

exist,  as  shown  by  its  occurring  numerously  in  one  individual  (phalanges, 
ribs,  &c.)  It  affects  young  persons  more  especially,  although  we  have 
known  examples  of  enchondromata  first  becoming  developed  at  an 
advanced  period  of  life.  Here,  however,  they  are  usually  concurrent 
with  exostoses  and  bulky  osteophyte  forms.  Echondroma  generally 
imitates  the  permanent  cartilages ;  with  exceptions,  however, — for  it 
ossifies. 

Not  only  have  we  seen  in  all  enchondromata  incipient  ossification,  but 
our  museum  contains  specimens,  for  the  most  part,  if  not  thoroughly 
ossified. 

Ossified  enchondroma  is  sometimes  a  white,  extraordinarily  dense, 
ivory-like,  sometimes  a  yellowish-white,  likewise  very  dense,  although 
uncommonly  brittle,  bony  substance,  deviating  in  various  degrees  and 
various  ways  from  the  texture  of  normal  bone.  This  difference  of  habit 
corresponds  to  a  different  process  of  ossification,  and  to  a  different 
elementary  texture. 

In  the  first  place,  we  miss  the  laminated  structure  of  true  bone.  The 
medullary  canaliculi  are  present,  the  bone-corpuscles  large,  spherical, 
irregularly  grouped,  wanting  in  radiations. 

In  the  next  place,  and  this  refers  to  the  second  form  of  bony  substance 
adverted  to,  the  process  of  ossification  recedes  still  further  from  the 
normal.  It  resembles  rather  a  process  of  involution,  a  wearing  out  of 
the  cartilage,  and,  like  the  texture  itself,  it  has  its  analogies  in  ossifica- 
tion of  the  larnyx,  and  above  all,  of  the  cartilages  of  the  ribs.  The 
intercellular  substance  of  the  hyaline  enchondroma  becomes  dull,  granu- 
lated, sallow,  lardaceous,  and  fibred.  The  cells  are  centrally  transformed 
into  spherical  bone-corpuscles  without  radii,  or  else  the  entire  large  cell- 
cavities  are  simultaneously,  if  not  previously,  filled  with  bone-earth. 
They  are  interspersed  without  order,  the  last  mentioned  forming  com- 
prehensive spherical  or  oval  masses,  which,  with  transmitted  light,  appear 
black,  and  have  a  diameter  of  ygth  of  a  millimetre.  The  lamellated 
structure  is  wanting.  Medullary  canals  are  wanting,  or  rudiments  only 
of  their  structure  are  seen  in  the  scattered  grouping  of  the  cartilage- 
cells. 

Enchondroma  commonly  occurs  in  a  simple  form.  We  have,  however, 
encountered  it  in  the  shape  of  little  millet  or  hempseed-sized  tubercula, 
interspersed  through  medullary  carcinoma  of  the  testicle,  an  occurrence 
allied  to  the  frequent  entering  of  true  bone  into  the  composition  of 
cancers. 

5.   BONE-FORMATION. 

Bone-formation  comprises  various  new  growths,  which,  in  their  de- 
veloped stage,  are  readily  divided  into  two  classes,  according  to  the 
analogy  which  their  texture  bears  to  that  of  normal  bone.  Still  the  line 
of  demarcation  is  not  sharply  drawn,  owing  to  the  multiplicity  of  transi- 
tion forms  from  the  one  to  the  other.  The  one  category  comprises  new 
growths  identical,  or  nearly  identical  with,  the  other,  a  series  of  new 
growths  less  or  more  widely  discrepant  from  the  texture  of  normal  bone. 
On  a  closer  scrutiny,  however,  this  series  again  separates  into  the  osteoid, 


BONE-FORMATION.  145 

and  into  the  bony  concretion,  which  latter  manifests  itelf,  more  especially 
in  fluid  blastemata,  as  cretef action. 

It  is,  indeed,  worthy  of  preliminary  remark,  that  not  alone  solid  blas- 
temata and  perfected  textures,  but  also  fluid  blastemata.  afford  the  basis 
of,  and  are  liable  to,  so-called  ossification. 

The  process  which  involves  the  conversion  of  the  substances  here 
alluded  to  into  bone,  is  commonly  termed  ossification,  and  thus  brought 
into  kindred  relation  with  the  bony  conversion  of  cartilage. 

We  have  here  to  observe  : 

1.  In  the  first  place,  amongst  the  pathological  growths  with  which  we 
are  here  more  especially  concerned,  are  ossifications  for  the  most  part 
not  constructed  upon  a  preformed  cartilaginous  base,  whilst  many  of 
them  deviate  from  the  course  and  the  results  of  the  ossifying  process  of 
bone-cartilage.     It  will  be  seen  that  in  these  last  referred  to,  there  is  an 
absence  of  the  vascularization  proper  to  the  cartilage  in  its  transition  to 
bone,  an  absence  of  that  lamellated  structure-development,  with  that 
grouping  of  the  cartilage-cells,  and  that  resulting  arrangement  of  the 
bone-cells,  which  both  exhibit  in   common.     In  isolated  cases,  as,  for 
instance,  in  the  ossifying  of  enchondroma,  it  is  not  in  the  intercellular 
substance,  but  in  the  cartilage-cell,  that  the  ossification  first  commences. 
That  ossified  enchondroma  differs  in  essential  points  from  the  texture  of 
true  bone,  we  have  already  seen. 

Where  no  preformed  cartilage,  but  rather  a  rude,  firm,  sod-like,  and 
fibrous,  or  a  fluid  blastema,  or,  again,  an  anomalous,  mostly  fibroid 
texture,  constitutes  the  groundwork  of  the  ossification,  the  result  is  a 
concretion  more  or  less  uniformly  penetrated  by  bone-earths,  and  pre- 
senting scarcely  any  analogy  with  the  texture  of  bone. 

2.  The  characters  of  ossification  differ  according  to  certain  differences 
in  the  implicated  textures  ;  or,  where  the  textures  are  identical,  according 
to  certain  peculiarities  in  the  process  itself. 

The  ossification  of  a  cartilaginous  base  has  frequently,  although  not 
always,  an  import  coequivalent  with  that  of  ossified  bone-cartilage — in 
other  words,  the  import  of  a  progressive  metamorphosis  into  a  complex 
vascularized  texture.  Genuine  bone-texture,  on  the  other  hand,  can,  in 
the  present  state  of  our  knowledge,  be  traced  to  a  cartilaginous  base 
alone,  the  pre-existence  of  which,  if  not  obvious,  must  be  taken  for 
granted. 

The  ossification  of  other  textural  bases,  on  the  contrary,  has,  if  we 
take  into  account  other  collateral  changes  which  these  bases,  and  more 
especially  the  fibroid  textures,  undergo,  the  import  of  a  retrogressive 
metamorphosis,  of  a  decay,  of  a  destruction  of  the  base.  With  the  dis- 
play of  lime-earths  in  the  shape  of  black  molecules,  the  textures  lose 
their  color,  their  succulence,  and  their  elasticity,  waste,  shrivel,  toughen, 
dry  up,  and  become  more  or  less  lardaceous.  Not  alone  do  no  new 
bloodvessels  make  their  appearance,  but  old  ones,  if  there  be  any,  be- 
come obliterated.  Fluid  blastemata  in  the  course  of  cretefaction  become 
turbid,  chalky,  gritty  to  the  feel.  Under  the  development  of  fat,  they 
form  into  a  pap,  and  eventually  thicken  down  to  a  mortar-like  concre- 
ment.  Even  in  cartilaginous  bases,  ossification  is  often  so  modified  as 

VOL.  I.  10 


146  BONE-FORMATION. 

to  represent  rather  a  retrogressive  than  a  progressive  metamorphosis 
(compare  enehondroma). 

3.  A  most  important  and  comprehensive  question  relative  to  ossifica- 
tion generally,  and  therefore  to  bone-cartilage  inclusive,  is :  whence  are 
the  lime-earths  which  incrust  and  penetrate  the  various  soft  textural 
bases  derived  ? 

A  narrow  scrutiny  of  the  ossifying  process,  especially  in  fibroid 
textures,  and  of  the  cretefaction  in  soft  and  fluid  blastemata,  will 
speedily  convince  us  that  the  appearance  of  lime-earths  is  not  essentially 
due  to  their  deposition  out  of  either  a  pre-existent  or  a  new-formed  and 
special  system  of  bloodvessels  within  the  ossifying  growth.  For,  when 
we  see  growths  ossify,  which  are  almost,  if  not  entirely  devoid  of  blood- 
vessels, and  which  are,  at  the  same  time,  remote  from  the  vascular 
system  of  other  formations  (for  instance,  free  bodies  within  serous  sacs) ; 
when  we  see  the  process  of  ossification  often  attended,  not  with  any  new 
growth  of  bloodvessels,  but  with  the  obliteration  of  existing  ones  ;  when, 
again,  we  reflect  upon  the  concomitant  changes  wrought  in  textures  dur- 
ing their  osseous  conversion,  their  wasting  and  discoloration,  the  inter- 
larding of  their  shrivelling  substance  with  free  fat,  we  are  fain  to  look 
upon  the  entire  process  as  the  result  of  the  total  transformation  of  the 
chemical  constituents ;  as,  in  fine,  an  elimination  of  pre-existent  lime- 
earths  out  of  their  primitive  connections. 

Even  in  the  normal  ossifying  of  boife-cartilage,  the  process  is  the  same 
at  the  commencement,  the  lime-earths  appearing  long  before  the  develop- 
ment of  any  vascular  system.  This,  then,  offers  at  least  one  connecting 
link  for  all  processes  of  ossification. 

In  the  revolutions  effected  by  the  ossifying  process,  a  most  important 
part  is  without  doubt  assignable  to  the  accession  of  fat.  It  is  common 
to  all  processes  of  ossification,  and  probably  results  both  from  a  release 
of  pre-existing  fat  from  its  primitive  combinations,  and  of  a  simultane- 
ous conversion  of  protein  substances  into  fat. 

From  these  preliminary  remarks,  we  may  at  once  proceed  to  a  muster 
of  the  new  growths  belonging  to  this  category,  premising,  however,  that 
much  relating  to  them  will  have  to  be  discussed  more  at  large  in  later 
chapters  of  the  present  work. 

1.  Uniform  or  almost  uniform  with  the  normal  bone,  are : 

(a.)  Bone  developed  in  permanent  cartilages,  and  especially  in  those 
of  the  larynx,  sometimes  and  in  part  also  the  ossifications  of  costal 
cartilages.  In  them,  however,  we  usually  miss  the  lamellated  structure 
of  normal  bone. 

(b.)  Bone-structures  which  form  as  callus  for  the  reunion  of  fractured, 
and  for  the  regeneration  of  lost  bone,  hyperostosis,  whether  external  or 
internal  (sclerosis),  exostoses,  and  all  osteophytes,  including  such  as  in 
the  shape  of  thorny,  stellate,  or  scaly  bone-growths  and  fabrics,  enter 
into,  and  sometimes  greatly  surpass  in  volume,  certain  concurrent  new 
growths,  especially  such  as  occur  in  bone. 

Notwithstanding  the  all  but  identical  relations  of  the  texture  of  these 
formations  with  that  of  normal  bone,  they  present  not  a  few  important 
discrepancies,  cognizable  both  by  a  general  comparison  with  normal 


BONE-FORMATION.  147 

bones,  and  by  a  special  comparison  with  those  directly  implicated. 
Thus,  as  examples,  we  may  adduce  the  inferior  vascularization,  inferior 
number  of  medullary  canals,  less  marked  lamellated  structure,  anomalous 
amount  and  irregular  disposition  of  the  bone-corpuscles,  in  the  new 
bone-growths. 

As  regards  the  process  of  ossification  in  the  several  blastemata,  that 
produced  by  inflammation  is  the  best  adapted  for  investigation,  as  being 
at  once  the  most  frequent,  and  the  most  voluminous.  The  flaky  or 
fibrous  basis  of  the  exudate  furnishes  the  fundamental  (intercellular) 
substance  of  the  cartilage.  Within  this  cells  become  developed,  which, 
following  the  process  of  physiological  bone-formation,  change  into  bone- 
corpuscles. 

(c.)  The  slowly  developed  bone-nuclei  in  callus,  arrested  at  the  stage 
of  a  ligamentous  formation  in  bone-fractures,  trephine-gaps,  &c. 

(d.)  Osseous  growths  developed  beyond  contact  with  bone  on  the  dura 
mater,  as  also  upon  the  cerebral  arachnoid,  and  upon  the  free  visceral 
plate  of  the  spinal  arachnoid  membrane ;  the  so-called  ossifications  upon 
the  intermuscular  ligaments  in  the  vicinity  of  hyperostosed  articulations, 
and  of  the  membrana  obturatoria  of  the  pelvic  foramen  ovale.  The  ossi- 
fications occurring  in  tendons  are  said  by  Henle  to  be  of  true  bone- 
texture,  as  are  also,  in  fine,  the  bony  concrements  found  impacted  within 
healthy  muscular  textures. 

2.  Osteoid. — Several  of  the  growths  adverted  to  as  deviating  in  cer- 
tain points  from  standard  bone-texture,  might  be    transferred  to   this 
section.     To  it,  however,  belong  more  especially  ossifications  of  costal 
cartilages,  and  most  of  all  ossifying  enchondromata,  both  in  bones,  and 
in  soft  parts.     In  bone  there  occur  independent   texture-supplanting 
tumors,  which  consist  of  an  ivory-like,  dense,  white  bone-substance,  and 
which  are  seen  both  in  this,  and  in  their  general  character  to  be  ossified 
enchondromata. 

Miiller's  osteoid  is  a  bone-formation  which  enters  redundantly  into  the 
parenchyma  of  cancer.  Its  constitution  is  identical  with  that  of  true 
bone,  and  it  will  be  discussed  under  the  head  of  Cancers. 

3.  Concretions. — Under  certain,  as  yet  unknown,  conditions,  the  lime- 
salts  in  a  soft  basis  are,  by  dint  of  a  revulsive  metamorphosis,  set  free 
so  as  to  incrust  and  penetrate  the  said  basis, — in  a  word,  effect  its  ossi- 
fication. 

Such  bases  are  the  fibroid  textures  and  blastemata  occurring  in  the 
form  of  independent  tumors,  of  membranous  expansions,  or  of  irregular 
masses  lodged  and  entangled  within  various  parenchymata.  They  may 
be  the  product  of  inflammation  (exudation),  or  merely  of  an  anomalous 
act  of  nutrition.  The  blastema  may  moreover  be  extravasate-fibrin,  or 
spontaneous  fibrin-coagulate  within  the  vascular  apparatus.  Such  bases 
are  fibrous  tumors,  fibroid  hardened  exudates  upon  normal  and  anoma- 
lous serous  membranes,  within  parenchymata,  in  the  cutis  as  scar-tex- 
ture, on  the  heart's  valves,  in  muscles,  in  the  heart's  walls.  Such,  again, 
are  the  central  and  the  peripherous  fibrinous  deposits  in  extravasates, 
after  entering  upon  a  fibroid  transformation,  hypertrophous  thickenings 
of  serous  membranes  and  of  the  tunicas  albuginese.  Such  are,  in  fine, 
the  Pacchionic  bodies,  the  different  fibrin  coagula  in  the  heart's  cavities 


148  BONE-FORMATION. 

(so-called  vegetations),  the  stratiform  deposits  within  arteries,  and  the 
soft  matrix  of  the  phlebolite  in  veins.  To  sum  up,  therefore — all  the  so- 
termed  ossifications  of  serous  membranes,  of  the  thyroid  gland,  of  the 
heart's  valves,  of  fleshy  muscle,  of  arteries,  and  of  veins. 

Even  the  fibroid  fabric  which  enters  into  the  composition  of  malignant 
growths,  for  example  of  cancers  in  soft  parenchymata,  now  and  then 
ossifies  into  a  bony  skeleton,  or  shell-like  framework.  This  is,  however, 
not  to  be  confounded  with  the  thorn-like,  stellate  and  scaly  stroma  of 
true  bone-texture,  accompanying  numerous  heterologous  growths  as  de- 
veloped in  and  upon  the  bones. 

The  ossification  offers  little  or  no  analogy  with  normal  bone,  and  its 
development.  The  bone-earth  enters  in  a  molecular  form,  accumulating, 
for  the  most  part  irregularly,  in  the  soft  basis,  until  the  latter  is  con- 
verted into  compact  bone.  The  bone-earth  is  capable  of  being  with- 
drawn by  acids,  with  restoration  of  the  soft  basis.  It  has  sometimes 
acquired  the  aspect  of  a  stratiform  deposit.  Many  a  wide-spreading 
ossification, — of  the  arteries  for  example, — is  concurrent  with  excessive 
fat-production  in  its  vicinity. 

4.  Crete/action.  Finally,  fluid  blastemata  are  also  liable  to  ossifica- 
tion. The  process  is  perfectly  identical  with  that  which  takes  place  in 
the  fibroid  blastemata  just  enumerated.  It  is  in  like  manner  conditional 
upon  a  metamorphosis  of  the  fluid  blastema,  by  virtue  of  which,  the  in- 
corporated lime-earths  being  set  free,  predominate.  Morphologically 
speaking,  the  blastema  displays  the  development  of  free  or  of  celled 
molecules  (granule-cells).  It  is  always  accompanied  by  fat  in  a  mole- 
cular form,  and  by  cholesterine  crystals.  The  ossification  manifests 
itself  as  a  lardaceous  chalky  pulp,  as  a  cement-like  and  friable,  ulti- 
mately, as  a  compact  calculus-like  growth. 

The  blastemata  entering  into  this  process  are  either  originally  fluid, 
or  else  originally  solid,  and  subsequently  liquefied  (croupous  fibrin). 

These  blastemata  are  either  exudates  external  to  the  vascular  system, 
or  deposits  internal  to  the  latter,  for  instance,  accumulated  layers  within 
the  arteries,  the  basis  of  vein-stones  in  the  veins,  or  coagula  smaller  or 
greater  in  extent  (vegetations). 

To  this  series  belong  the  cretefactions  of  fibrinous,  albuminous  exu- 
dates, of  pus,  of  tubercle,  of  atheroma  in  arteries,  of  vegetations  on  the 
heart's  valves,  of  coagula  in  the  veins.  Just  like  ossification,  crete- 
faction  presents  various  grades  from  the  aforesaid  progressive  pulp-like 
thickening,  to  the  cement-like,  and  at  length  the  compact,  calculous 
concretion. 

A  very  peculiar  kind  of  ossification  is  represented  in  the  cell-incrus- 
tations, which  have  their  physiological  analogues  in  the  pineal  concre- 
tions. They  appear  in  a  variety  of  shapes  in  the  vascular  plexuses, 
especially  in  the  turbid,  chalky,  speedily  condensing  moisture  of  the 
cysts  of  the  choroid  plexus,  as  also  in  sarcomata  and  cancers,  more 
especially  within  the  brain.  The  cells  both  as  primary  and  as  parent- 
cells,  together  with  their  contents,  fill  with  lime-salts,  now  in  a  mole- 
cular shape,  now  in  that  of  concentrical  layers. 


GROWTH     OF    BLOODVESSELS.  149 


6.    GROWTH    OF   BLOODVESSELS. 

Setting  aside  all  dilatations  of  the  smaller  vessels  and  capillaries, 
constituting  the  so-called  aneurysma  anastomoticum  and  telangiectasis, 
we  shall  here  treat  of  all  that  concerns  the  new  growth  of  bloodvessels. 

Upon  a  somewhat  slender  foundation  of  facts  with  which  we  have  to 
commence,  we  must  endeavor  to  build  up  a  superstructure  of  well-consi- 
dered hypothesis. 

1.  The  common  occurrence  of  this  new  growth  in  inflammatory  pro- 
ducts is  incontestable,  more  especially  in  the  adventitious  membranes, 
affecting  serous  tunics.  It  is  at  the  same  time  matter  of  certainty  that 
such  new  vessels  by  no  means  originate  through  any  prolongation  of 
pre-existent  vessels  in  the  contiguous  textures,  but  that  the  new  process 
of  development  is  altogether  an  independent  one,  and  that  only  at  a 
later  epoch  do  the  new-formed  vessels  enter  into  anastomosis  with  the 
older  ones. 

The  process  of  the  new  growth  of  bloodvessels  in  inflammatory  pro- 
ducts of  this  kind  is  as  follows : 

In  the  first  place,  blood  is  seen  to  occupy  little  vacant  spaces  within 
the  blastema  or  exudate  thrown  out  in  consequence  of  the  inflammatory 
stasis.  In  other  words,  certain,  for  the  most  part  irregularly  spherical, 
ramified,  to  the  naked  eye  point-like,  areas,  unlined  with  any  proper 
membrane,  fill  with  blood ;  areas  obviously  determined  by  the  upspring- 
ing  of  blood  out  of  the  blastema.  Both  their  remoteness  from  old 
vessels,  and  their  ulterior  development,  controvert  the  idea  of  the  con- 
tained blood  consisting  of  little  extravasates.  This  blood  represents  an 
aggregate  of  blood-corpuscles  which  the  concurring  testimony  of  Vogel 
and  myself  has  shown  to  be  of  various  magnitude,  for  the  most  part 
imperfectly  round ;  not  precisely  disk-like,  nor  possessed  of  the  intense 
redness  of  old  blood-corpuscles.  They  are  moreover  soft,  and  adhere 
both  to  each  other  and  to  the  parietes  of  the  containing  areas.  From 
these  areas  there  are  gradually  developed  in  all  directions,  sometimes, 
however,  predominantly  in  a  single  one,  blood-streamlets  contained 
within  chinks  or  canals  in  the  blastema,  and  having  no  perceptible  con- 
fining membrane.  In  minuteness  of  calibre,  they  excel  the  finest  capil- 
laries. Their  next  step  is  to  become  invested  with  a  structureless 
confining  membrane,  the  internal  bloodvessel  membrane,  to  which  the 
outer  layers  associate  themselves  by  and  by.  Finally  they  shoot  out 
from  various  centres  to  anastomose  with  one  another,  and  eventually 
with  the  old  textural  vessels. 

In  this  process  two  material  points  remain  unaccounted  for,  namely, 
first,  the  primitive  development  of  the  blood-corpuscles  in  those  central 
areas.  The  question  is — their  spontaneous  and  independent  origin  out 
of  the  common  blastema  being  manifest,  what  portion  of  the  latter  is 
devoted  to  this  purpose,  and  what  chemical  changes  does  the  act  involve? 

Secondly :  How  do  the  vessels  originate  ?  In  reference  to  the  last 
question  it  may  be  asserted : 

(a.)  If  we  may  judge  from  past  observations,  the  vessels  in  these  bias- 


temata  do  not  spring  from  primary  blood-holding  cells.     The  absence 
at  first  of  anv  sharply  defined  conto 


any  sharply  defined  contour  in  the  said  areas  disproves  their 


150  GROWTH    OF    BLOODVESSELS. 

being  primitive  cells,  or  the  blood-streamlets  emanating  from  them, 
prolongations  of  cells.  This  leads  us  to  the  more  probable  assumption 
that: 

(b.)  The  blood  forms  out  of  the  blastema  generally,  and  where  the 
latter  has  wrought  itself  into  cells,  not  within  these,  but  in  intercellular 
spaces  between  them.  Where,  however,  blood  and  bloodvessel  forma- 
tion frequently  precede  cell-development,  and  more  especially  where  it 
takes  place  in  blastemata  in  which  cell-development  is  either  wanting 
altogether,  or  plays  only  a  very  subordinate  part  (for  example,  in  fibroid 
blastemata),  it  can  only  be  alleged  that  the  formation  takes  place  in 
chinks  and  chamberlets  worked  out  of  the  blastema  by  the  blood  itself. 
The  structureless  membrane  which  subsequently  confines  the  blood 
streamlets,  is  in  all  likelihood  a  secondary  endogenous  formation  out  of 
the  blood,  the  remaining  layers  being  built  over  it,  so  to  speak,  exter- 
nally, out  of  the  blastema. 

As  regards  the  relation  of  new  bloodvessel  development  to  the  cha- 
racter of  the  blastema,  the  following  points  seem  to  present  themselves 
for  further  inquiry. 

(a.)  In  different  products  of  inflammation,  there  is  virtually  a  very 
different  degree  of  proneness  to  the  new  growth  of  bloodvessels.  In 
some  it  is  excessive,  in  certain  others,  in  the  progress  of  development 
into  precisely  the  same  texture  (the,  areolar),  it  is  very  faint  indeed. 
Upon  the  parietal  layer  of  the  cerebral  arachnoid,  adventitious  mem- 
branes occur,  which  along  with  an  inconsiderable  amount  of  nuclei,  of 
nucleated  cells,  and  of  areolar-tissue  fibrils,  consist  mainly  of  blood- 
vessels. 

(b.)  The  new  growth  of  bloodvessels  is  directly  proportionate  to  the 
general  capacity  of  the  blastema  for  textural  change.  Blastemata 
which  linger  long  in  their  primitive  crude  condition,  and  also  which 
serve  for  the  groundwork  of  indistinct  fibroid  textures,  exhibit  little,  if 
any,  new  growth  of  bloodvessels. 

The  new  formed  vessels  give  token  of  a  delicacy  of  structure,  and  a 
vulnerability  in  full  accordance  with  their  recent  origin.  To  this  are 
probably  due  the  hemorrhagic  products  upon  their  becoming,  when  only 
just  formed,  the  seat  of  inflammatory  stasis.  The  fact  is,  moreover,  to 
be  inferred  from  the  new-formed  vessels  originally  consisting  of  the 
primitive  vessel-membrane  alone  ;  and  not  until  a  later  period  attaining 
the  perfected  organization  of  old  bloodvessels.  In  new-formed  vessels 
of  considerable  calibre,  we  have  frequently  missed  the  layer  of  trans- 
verse-oval nuclei. 

The  vascular  apparatus  of  new  growth  is  marked  by,  for  the  most 
part,  long,  stretched  vessels,  by  rare  dichotomous  ramification,  with 
hardly  perceptible  decrease  of  calibre,  or  by  a  wide-meshed  disposition. 

A  nervous  system  has  not  as  yet  been  demonstrated  in  them. 

The  new  bloodvessels  both  in  the  spurious  membranes  adverted  to, 
and  also  in  other  new  growths,  are,  as  experience  has  again  and  again 
shown,  susceptible  of  inflammation,  and  this  in  very  early  stages  of  their 
development.  Here,  for  reasons  both  self-evident  and  already  referred 
to,  they  are  wont  to  yield  essentially  hemorrhagic  products. 

The  manner  in  which  their  anastomosis  with  old  vessels,  or  with  par- 


GROWTH    OF    BLOODVESSELS.  151 

ticular  arteries  or  veins  is  effected,  has  not  been  thoroughly  made  out 
by  experiment.  As  regards  the  former  case,  it  is  probable  that  the 
anastomosis  is  brought  about  by  an  act  of  resorption  in  the  wall  of  the 
old  vessel,  at  the  point  where  the  new  vessel  rests. 

With  respect  to  the  second  point,  Van  der  Kolk  has  distinctly  shown 
that  in  the  case  of  adhesions  of  the  lung  to  the  costal  parietes,  a  con- 
nection becomes  established,  on  the  one  side  with  the  system  of  the 
pulmonary  artery,  on  the  other  side  with  the  aortic  circulation.  And 
although  this  fact  may  not  warrant  all  Van  der  Kolk's  deductions,  it  is 
nevertheless  highly  important,  as  offering  a  connecting  link  with  other 
observations  of  his  own  upon  anastomoses,  to  which  we  shall  hereafter 
have  to  revert. 

New-formed  vessels  doubtless  undergo  obliteration  in  spurious  mem- 
branes, just  in  the  same  gradual  manner  as  in  the  cicatrix,  and  probably 
for  the  most  part  in  the  progress  and  sequel  of  the  retrogression, — the 
wasting — of  the  new  textures  themselves. 

2.  As  in  inflammatory  products,  so  also  in  other  blastemata,  does  a 
new  growth  of  bloodvessels  occur.  An  examination  of  these  proves 
incontestably  that  there  is  a  second  mode  in  which  a  new  growth  of 
bloodvessels  may  take  place.  We  have  satisfied  ourselves  of  the  deve- 
lopment of  neiv  vessels  out  of  parent-cells  in  cancerous  structures,  com- 
posed, amongst  other  elements,  of  spherical  or  acinus-shaped  parent- 
cells.  Numerous  cyst-like  cells,  with  structureless  parietes,  contained 
in  place  of  the  brood  cells  of  carcinoma,  soft,  adherent  blood-corpuscles. 
Many  of  them  bulged  out  in  all  directions  into  coecal  sacs,  freighted 
with  the  same  contents,  and  entering  into  anastomoses  with  others. 
Blastemata,  therefore,  entering  into  cell-development,  are  in  reality 
capable  of  producing  a  new  development  of  bloodvessels  out  of  cells. 

Certain  new  growths  are  remarkable  for  being  rich,  others  for  being, 
in  various  degrees,  poor  in  bloodvessels.  The  former  are  mostly  loose 
in  texture,  and  consequently  capable  of  considerable  intumescence. 
Their  hyperremiae  are  for  obvious  reasons,  readily  exaggerated  into 
hemorrhage,  and  their  inflammation  is  especially  liable  to  determine 
hemorrhagic  products.  Amongst  the  malignant  new  growths,  medul- 
lary cancer  is  notorious  in  this  respect.  Its  highly  developed  vascular 
apparatus  is  doubtless  the  source  of  its  excessive  nutrition,  of  its  rapid 
and  often  monstrous  growth.  It  .is  pronounced  by  Van  der  Kolk  to  be 
of  arterial  nature,  in  other  words,  to  anastomose  with  arteries  only. 

Very  vascular  new  growths  form  the  transition-link  to  nearly  pure 
bloodvessel-formation.  For  blastemata  are  not  wanting  which  present 
almost  exclusively  the  groundwork  of  new  bloodvessel-formation — in 
other  words,  of  a  new  growth,  consisting  almost  exclusively  of  new 
bloodvessels. 

To  this  class  belong  the  following  new  growths,  concerning  the  deve- 
lopment and  import  of  which  much  obscurity  still  prevails. 

(a.)  Cavernous  textures,  cavernous  blood-tumors. — These  growths  are 
of  a  cancellated  structure,  somewhat  resembling  that  of  the  corpora  ca- 
vernosa.  They  consist  of  areolar  tissue  fibres,  constituting  a  multilocu- 
lar  stroma,  the  interspaces  of  which  are  invested  with  a  structureless 
membrane,  and  contain  blood.  Numerous  caudate  cells  liberated  during 


152  GROWTH    OF    BLOODVESSELS. 

m 

the  investigation  appear  to  be  the  debris  of  an  epithelium.  The  inter- 
cellular spaces  communicate  amongst  each  other ;  for,  by  pressure,  the 
tumor  may  be  completely  emptied  through  a  cut  surface.  They  are  sur- 
rounded by  a  tolerably  dense  capsule  of  areolar  tissue,  along  with  which 
they  may  be  peeled  out  of  the  textures.  They  always  communicate  with 
a  considerable  vein,  through  which  they  will  take  up  an  injecting  mass. 
No  arterial  ramification  is  demonstrable  within  their  texture.  They 
are  very  tumefiable,  forming  upon  the  surface  of  the  body  and  at  the 
periphery  of  organs,  protuberant,  compressible,  but  resilient  dark-blue 
tumors,  which  supplant  the  original  textures. 

They  are  commonly  regarded  as  telangiectases,  and  without  doubt 
they  pass,  with  many  practitioners,  for  examples  of  fungus  haematodes. 
By  the  French  (An dral),  they  are  termed  "spurious  spleens"  (After- 
milzen),  "placenta-like  textures."  In  our  opinion,  they  are  by  no  means 
dilatations  of  bloodvessels,  but  to  all  intents  and  purposes  new  growths, 
and,  as  far  as  our  experience  goes,  altogether  benign.  We  have  never 
seen  them  concurrent  with  a  malignant  growth.1 

Their  mode  of  development  is  not  clearly  made  out.  Numerous  ob- 
servations, however,  render  it  probable  that  they  originate  as  blood- 
vessel growths  in  their  most  extended  sense,  as  blood-bearing  depots 
and  canals,  formed  by  absorption  out  of  a  solid  blastema.  Whether  the 
contained  blood  be  a  primitive  endogenous  new  growth,  or  become  intro- 
duced into  it  subsequently,  we  know  not.  Thus  considered,  they  bear 
a  close  analogy  with  the  fenestrate  and  canal  formation  in  certain  blas- 
temata  pertaining  to  the  vascular  system,  in  the  superincumbent  layers 
upon  the  inner  membrane  of  arteries,  in  the  fibrinous  coagula  within  the 
vascular  system,  in  the  thrombus,  &c. 

Within  the  cancelli  small  concretions  occasionally  form,  corresponding 
to  the  phlebolites  of  veins. 

We  have  seen  these  cavernous  textures  developed  in  the  subcutaneous 
areolar  tissue  of  the  thigh,  and  communicating  with  the  saphena  vein,  as 
also  in  the  substance  of  the  lips.  We  have  seen  them  as  tumors  grow- 
ing out  of  the  diploe  of  the  skull-bones,  and  penetrating  the  compact 
outer  skull-plate,  and,  again,  in  the  texture  of  the  pia  mater.  They  are 
the  most  frequent  of  all,  and  the  most  various  in  dimensions,  up  to,  and 
beyond  those  of  a  duck's  egg,  in  the  liver,  where  they  communicate  with 
branches  of  the  portal  vein. 

(b.)  Fungus  hcematodes,  blood  fungus. — What  is  commonly  held  to 
be  fungus  hcematodes,  is  a  luxuriant  vascular  growth,  mischievous,  both 
from  its  liability  to  occasional  hemorrhage,  and  from  its  tendency  to  ex- 

1  The  author  has  since  modified  his  opinions  respecting  these,  so-called  "  cavernous  tex- 
tures." Abandoning  the  ground  of  their  development  out  of  a  solid  blastema  through  partial 
resorption,  he  now  regards  their  stroma  as  nearly  identical  with  that  of  cancerous  struc- 
tures, both  in  its  elementary  constitution,  and  in  the  fact  of  the  same  dendritic  excrescences 
springing  from  its  septa,  and  growing  into  its  chamberlets.  The  affinity  of  these  tumors  to 
cancer,  the  author  considers  further  established  by  their  not  unfrequent  concurrence  in  the 
same  organ  (the  liver,  for  instance)  with  cancerous  tumors. 

Incipient  cavernous  tumors  do  not,  it  is  asserted,  present  any  anastomosis  whatever  with 
the  venous  system.  The  anastomosis  is  established  only  at  a  later  period  through  the  me- 
diation of  very  minute  venous  offshoots.  It  is  not  made  clear,  however,  in  what  manner 
this  communication  is  brought  about.  (See  Rokitansky  "  iiber  die  Entwickelung  der  Krebs- 
geriiste."  Sitzungs-berichte  der  Kais.  Akad.  der  Wissenschaften,  Milrz,  1852.) — ED. 


TH    OF    BLOODVESSELS.  153 


haust  the  constitution  by  the  habitual  hemorrhage  consequent  upon  its 
ulceration.  Some  deem  it  curable  by  removal  with  the  knife,  whilst 
others  maintain  that  it  invariably  recurs  either  at  the  same  spot  or  else- 
where, and  that  it  is  of  cancerous  nature.  Some  even  fancy,  that  not 
only  does  it  return  in  its  primitive  form,  but  that  it  may  be  replaced  by 
another  form  of  o  he  medullary  or  encephaloid. 

Our  own  opinion  .g  the  occurrence  of  fungus  hsematodes,  is  to 

this  effect : 

1.  It  is  incontestable   that   highly  developed,  bleeding,  ulcerating 
tdangiectaseS)  as  also  Cavernous  textures,  are  frequently  mistaken  for 
fungus  hcematodes.    This  applies  still  more  forcibly  to  a  highly  vascular, 
bleeding,  ulcerating,  blood-turgid  medullary  carcinoma.     Nay,  we  have 
often  seen  a  turn  osed  as  fungus  hsematodes,  resolve  itself  in  the 
dead  subject,  after  collapse  of  the  bloodvessels  had  taken  place,  into  a 
medullary  carcinoma. 

2.  We  are  convinced  of  the  existence  of  new  growths  almost  wholly 
made  up  of  bloodvessels  ;  we  even  regard  it  as  likely  that  the  so-termed 
telangiectases  (both  congenital  and  adventitious)  are,  for  the  most  part, 
new  growths  of  bloodvessels. 

The  question  with  respect  to  such  luxuriations  of  bloodvessels  is,  what 
is  it  that  determines  their  (innocent  or  malignant)  character  ?  We  be- 
lieve this  to  reside,  not  in  the  bloodvessel  growth,  but  in  the  remaining, 
namely,  the  intervascular,  portion  of  a  common  blastema  ;  just  as  in  the 
malignant  osteoid,  not  the  bone-luxuriation,  but  the  adjacent,  soft  hetero- 
logous  parenchyma,  determines  its  cancerous  nature.  Scanty  as  is  the 
proportion  of  this  intervascular  heterologous  substance  to  the  blood- 
vessel growth,  the  former  merits,  in  this  sense,  the  most  ample  consi- 
deration, and  however  important  bloodvessel  luxuriation  in  itself  may 
be,  the  term  fungus  hcematodes  designates  but  a  secondary  feature  of 
the  entire  new  growth,  a  modification,  through  accidental  excess  of  vas- 
cularity,  of  a  new  growth  well-marked,  only  imperfectly  examined.  The 
designation  vascularized  areolar  tissue  or  vascular ized  cancerous  for- 
mation, would  be  both  more  philosophical  and  more  practical. 

Hence  the  benign  or  malignant  character  of  a  new  growth  associated 
with  excessive  vascularity  would,  in  such  cases,  be  primitive. 

Can  the  benign  new  growth  of  this  kind  become  malignant  ?  It  can 
hardly  be  doubted  that  vascular  tumors  may  accidentally  become  the 
nidus  of  a  malignant  new  growth,  just  as  may  any  natural  organ  rich  in 
bloodvessels. 

Another  kind  of  consecutive  degradation  to  malignancy  is  also  con- 
ceivable, although  for  the  present  little  more  than  hypothetical. 

To  explain  our  meaning  it  will  be  necessary  to  enter  upon  a  little 
further  discussion. 

Bloodvessel  luxuriations  represent,  when  the  anastomoses  with  the  old 
vessels  are  completed,  a  new  vascular  apparatus  complete  within  itself,  a 
repetition,  so  to  speak,  of  the  portal  system. 

The  anastomoses  might  be  of  such  a  character  as  to  attach  solely 
either  to  the  arterial  or  to  the  venous  system.  Van  der  Kolk  considers 
this  proved,  maintaining  that  medullary  carcinoma  belongs  exclusively 


154  FAT-TEXTURES. 

to  the  arterial,  and  another  new  growth,  which  he  denominates  fungus 
hsematodes,  to  the  venous  system  alone. 

A  vascular  apparatus  of  this  kind  not  being  conceivable  without  inter- 
change of  matter,  it  might  be  not  unreasonably  inferred — 

1.  That  the  products  of  such  a  process  would  differ  according  to  the 
arterial  or  to  the  venous  nature  of  the  blood  circulating  in  the  tumor, 
and  that  the  products  would  be  more  especially  anomalous  where  blood, 
previously  rendered  venous,  has  to  permeate  a  secondary  system  of  capil- 
laries.    In  both  cases  the  circulation  must  needs  become  torpid,  and 
prone  to  undergo  stases. 

2.  That  the  crasis  of  the  general  circulation  must  suffer  a  change, 
more  especially  in  the  second  case. 

In  such  wise,  vascular  luxuriations  might  indeed  be  imagined  to  pass 
into  malignant  new  growths,  the  product,  namely,  of  their  interchange 
of  matter  constituting  a  malignant  blastema. 

The  new  formation  of  lymphatics  has  been  demonstrated  by  Van  der 
Kolk  in  adventitious  membranes  and  in  cancers. 

7.    FAT  FORMATION,  FATTY  DEGENERATION. 

The  anomalous  occurrence  of  fat  is  no  less  frequent  than  multiform. 
The  subject  is  daily  acquiring  fresh  interest,  in  proportion  as  the  im- 
portance of  fat  in  the  animal  economy,  from  the  incipient  stage  of 
digestion  through  every  process  of  assimilation,  up  to  the  formation  of 
the  elementary  cell,  renders  itself  more  and  more  apparent.  It  is,  how- 
ever, quite  within  the  compass  of  pathological  anatomy  to  testify  that 
protein  substances,  and  in  particular  fibrin  and  albumen,  are  capable  of 
undergoing  conversion  into  fat. 

FAT-TEXTURES. 

1.  Normal. — We  have  already  adverted  to  the  excessive  formation  of 
fat  generally,  and  to  its  accidental  unequable  accumulation  about  certain 
organs,  amid  general  wasting  of  this  tissue,  for  example,  in  the  omentum, 
the  kidneys,  the  mediastina,  on  the  pericardium,  and  on  the  heart.  We 
have  here  to  advert  more  particularly  to  fat  collections  still  more  marked 
by  their  locality  and  limitation.  Of  this  kind  are — 

(a.)  Those  collections  of  fat  important  in  various  ways,  which  encircle 
diseased,  and  especially  calculous  kidneys,  or  such  as  have  become 
atrophied  through  Bright's  disease,  or  surrounding  anomalous  bone- 
formations  (offering  some  analogy  with  the  medullary  system  of  bone), 
as  in  ossifying  arteries,  in  the  vicinity  of  cancers,  &c. 

(b.)  Lipoma  or  fatty  tumor,  an  accumulation  of  adipose  tissue  in  the 
shape  of  a  spherical,  oval,  lenticular,  more  or  less  lobulated  tumor,  in- 
vested with  a  delicate  capsule  of  areolar  tissue,  and  permeated  by  equally 
delicate  and  spare  continuations  of  the  latter.  Its  size  is  from  that  of  a 
hemp-seed  or  a  pea,  to  that  of  a  man's  head,  or  more. 

It  consists,  as  a  mere  repetition  of  the  normal  adipose  tissue,  of  sphe- 
rical fat-cells,  wherein  are  discoverable  stellate  or  radiating  crystals  of 
margarine  or  margaric  acid.  Where  the  areolar  tissue  capsule  is  more 


FAT-TEXTURES.  155 

strongly  developed,  the  lipoma  is  an  encysted  one.     We  have  met  with 
such  encysted  portions  in  the  midst  of  loosely  lobulated  lipomata. 

The  lipoma  occurs  chiefly  in  the  subcutaneous  areolar  tissue,  more 
especially  in  localities  where  fat  is  deposited  in  more  than  ordinary 
amount  in  the  healthy  state,  and  where  accidental  circumstances  cause 
its  still  further  accumulation,  as  at  the  glutsei,  at  the  thighs,  at  the  back 
and  neck,  about  the  shoulder.  It  is,  however,  also  observed  in  parts  less 
abounding  in  fat,  as  beneath  the  hairy  scalp.  Again,  it  occurs  in  the 
submucous  areolar  tissue  of  the  stomach,  of  the  intestine,  even  of  the 
bronchia ;  in  the  subserous  areolar  tissue  of  the  parietal,  as  well  as  of 
the  visceral  layer,  although  more  commonly  of  the  parietal,  in  serous  and 
synovial  sacs ;  for  example,  beneath  the  pleura  and  peritoneum,  upon 
the  inner  surface  of  the  dura  mater,  and  upon  the  investing  membrane 
of  the  ventricles.  It  has  been  fully  described  as  it  occurs  in  synovial 
sacs,  more  especially  of  the  knee-joint,  in  that  peculiar  form  which  Joh. 
Miiller  has  denominated  lipoma  arborescens  ;  a  form  to  which  all  lipoma- 
tous  accumulations  beneath  serous  sacs  incline.  We  have  also  met  with 
lipomata  in  glandular  organs,  more  especially  in  the  lungs,  liver,  and 
kidneys,  in  bone  affected  with  osteoporosis  and  eccentrical  atrophy. 

Large  lipomata  in  subcutaneous  and  in  submucous  areolar  tissue,  by 
dint  of  traction,  acquire  a  pedicle,  and  lapse  into  the  cavity,  it  may  be 
of  the  intestine,  in  the  semblance  of  a  polypus. 

Lipomata  occur,  for  the  most  part,  solitarily.  Instances  are  not  quite 
rare,  however,  of  several,  or  even  many  coexisting  beneath  the  subcuta- 
neous areolar  tissue.  Such  cases  are  the  more  remarkable,  that  they 
may  affect  individuals  not  otherwise  at  all  prone  to  excessive  fat  forma- 
tion. 

In  itself  lipoma  is  innocent.  By  compression,  traction,  and  hampering 
of  space,  it  may  be  rendered  nocuous.  Moreover,  its  general  integument 
may,  through  violent  tension,  through  inflammation  and  suppuration,  or 
through  a  sloughing  process,  occasion  consecutive  ulceration  of  the  tumor, 
and  exhaustion  of  the  powers  of  life. 

It  is  seldom  traceable  to  palpable  mechanical  injury.  In  the  majority 
of  cases,  more  especially  where  several  lipomata  concur  or  succeed  each 
other  in  growth,  there  is  evidence  of  neither  blow  nor  compression. 

The  term  steatoma,  so  often  misapplied  of  old,  has  been  reserved  by 
Johannes  Muller  to  designate  a  peculiar  species  of  lipoma,  in  which  the 
fat  texture  is  lobulated,  as  it  were,  through  the  intervention  of  a  permea- 
ting membrane 'of  areolar  tissue,  the  latter  forming  a  main  constituent 
of  the  new  growth,  and  imparting  to  it  greater  toughness. 

2.  Abnormal  (fat-texture). — To  this  category  belong,  in  the  first 
place,  cases  in  which  the  contents  of  the  fat-cells  vary  from  the  natural 
character  ;  in  the  second  place,  cases  in  which  the  cells  themselves  deviate 
from  the  normal  type. 

(a.)  The  fat-texture  manifests,  under  certain  conditions,  anomalies  for 
the  most  part  referable  to  the  nature  of  the  contained  fat ; 

(a.)  The  latter  being  sometimes  preternaturally  diffluent,  like  oil-fat 
(oleine).  It  is  more  than  usually  unctuous.  On  pressure  or  incision  it 
gushes  forth  abundantly,  and  in  big  drops.  In  the  dead  subject,  neigh- 


156  FAT-TEXTURES. 

boring  parts  are  often  found  infiltrated  with  liquid  fat.  It  is  mostly 
tinged  of  a  deep  yellow,  and  resembles  marrow. 

These  characteristics  very  commonly  attach  to  the  fat  of  the  old  and 
cachectic,  laboring  under  osteoporosis  (from  atrophy),  extensive  ossifica- 
tion of  the  arteries,  osteomalacia  ;  and  of  younger  individuals  a  prey  to 
cancer.  Similar  properties  belong  in  an  especial  manner  to  fatty  accu- 
mulations usurping  the  place  of  muscle  or  of  pancreas-texture. 

(ft.)  The  fat  contained  within  the  cells  is  firmer,  stearine-like,  resem- 
bles mutton  suet,  and  dulls  the  blade  of  the  scalpel.  The  entire  fat  of 
the  individual  is  of  this  character,  more  especially  that  of  the  subcuta- 
neous adipose  tissue,  and  it  is  commonly  associated  with  strongly  de- 
veloped pigment  formation  in  the  rete  mucosum,  and  a  copious  secretion 
from  the  sebaceous  glands, — an  oily  skin.  These  properties  mark,  in 
an  especial  degree,  the  fat  of  younger  dram-drinkers,  and  are  almost 
without  exception  concurrent  with  lardaceous  affection  of  the  liver. 

This  variety  may  be  caused  by  the  fat  containing  a  larger  proportion 
of  margarine;  perhaps,  also,  by  the  development  of  stearine.  Spirit- 
drinking  has  a  very  marked  tendency  to  produce  it. 

(b.)  The  fat-texture  gives  evidence  of  anomalies  both  as  to  the  contents 
of  the  fat-cells,  and  as  to  the  properties  of  the  cell  itself. 

The  cholesteatoma  of  Johannes  Miiller  belongs  to  this  class.  It  is 
invariably  a  local,  circumscript  new  growth.  The  cholesterine  holding 
stratiform  fat-mass  consists  of  thin,  sometimes  concentrically  stratified, 
mother-of-pearl  like,  lustrous  plates  of  scales,  which,  on  a  closer  inspec- 
tion, appear  composed  of  partly  spherical  and  oval,  but  for  the  most 
part  polyedrical  vegetable-like  cells,  one-eighth  to  one-sixteenth  of  a 
millimetre  big.  This  texture  accords  with  that  of  the  tallowy,  adipose 
tissue  of  the  wether,  only  that  the  cells  are  smaller  and  more  delicate. 
The  majority  of  the  cells  do  not  appear  nucleated;  many  others, 
however,  more  especially  the  younger  spherical  cells,  show  distinct 
nuclei. 

Between  the  layers  of  this  polyedrical  cell-texture  are  visible  crystal- 
line deposits  of  fatty  substances,  mostly  in  the  shape  of  rectangular 
tables.  Barruel  found  them  to  contain  cholesterine  and  a  fat  akin  to 
stearine.  The  cholesteatoma  commonly  occurs  encysted  within  a  fibroid 
envelope,  or  within  a  cyst-membrane  lined  with  a  delicate  epithelium. 
We  have,  in  common  with  other  pathologists,  seen  it  thus  in  the  subcu- 
taneous areolar  tissue,  in  bones, — those  of  the  skull  in  particular, — in 
the  pia  mater,  and  in  the  brain.  Johannes  Miiller  met  with  it  in  cysto- 
sarcoma.  It  also  occurs  free,  in  the  shape  of  a  layer,  as  Cruveilhier  has 
observed  in  urinary  fistulae,  and  Johannes  Miiller  and  myself  upon  the 
surface  of  an  ulcerating  mammary  cancer.  In  our  own  case  it  was  upon 
the  sore  surface  of  a  fibrous  cancer  combined  with  epithelial  cancer.  We 
have  met  with  it  in  the  same  combination  upon  the  surface  of  a  sloughing 
ulcer. 

The  cholesteatoma  is  in  itself  innocent.  Inclosed  within  a  cyst  it 
usurps  the  place  of  surrounding  textures,  causing  the  forcible  expansion 
of  the  osseous  texture  in  bone,  and  occasionally  perforating  the  common 
integument,  when  subjacent  to  it,  becoming  destroyed,  and  thrown  off. 

3.  Free  Fats. — The   occurrence  of  free  fat, — a  condition,  we  think, 


FAT-TEXTURES.  157 

• 

properly  meriting  the  term  of  fatty  disease — takes  place  under  different 
circumstances  : 

1.  It  is  immediately  secreted  as  such.     The  seat  of  its  deposition 
are  normal  textures  and  their  elementary  parts,  or  else  pathological 
growths. 

To  the  former  category  belong : 

(a.)  Tallowy  infiltration  of  the  liver,  a  condition  in  the  one  instance 
resulting  from  spirit  drinking ;  in  the  other,  being  the  concomitant  of 
tuberculous  disease.  In  the  former  case  it  is  often  associated  with  a 
stearine-like  character  of  the  contents  of  the  adipose  tissue. 

(5.)  To  the  other  mode  of  occurrence  belong  more  especially  the  fatty 
contents  of  encysted  tumors. 

These  fats  differ  in  character.  Thus,  in  ordinary  fatty  liver  it  is  a 
normal  fat,  for  the  most  part  rich  in  elain, — in  some  varieties  of  fatty 
liver,  the  waxy  liver,  a  more  consistent  fat,  containing  stearine  and 
cholesterine. 

In  various  cysts,  again,  we  meet  with  a  fat  consisting  in  different  pro- 
portions of  elain,  margaric,  stearine-like  fat  and  butyrine.  Some  cysts 
contain  cholesterine  alone ;  the  majority,  other  ingredients  besides.  In 
this  mode  of  its  occurrence,  fat  is  very  generally  associated  with  epider- 
moidal  and  with  osseous  formation. 

2.  Fat,  as  such,  is  liberated  owing  to  new  combinations  taking  place 
amongst  the  ultimate  constituents  of  a  complex  formation.     Or,  again, 
it  is  not  set  free  as  pre-existent  fat,  but  is  newly  created,  and  this  out  of 
protein  substances,  by  dint  of  an  elementary  transforming  power. 

This  transformation  or  metamorphosis  into  fat  is  rendered  highly  pro- 
bable, if  not  certain : 

(a.)  By  the  large  proportion  of  fat  found  at  various  epochs  in  the 
place  of  parts,  into  whose  composition  fat  assuredly  did  not  originally 
enter  in  anything  approaching  to  its  subsequent  amount. 

(b.)  By  this  appearance  of  excess  of  fat  occurring  under  conditions 
which  preclude  its  derivation  from  a  vascular  system.  It  takes  place  in 
growths  destitute  of  bloodvessels  and  often  remote  from  vascularized 
organs ;  for  example,  in  exudates,  shut  up  within  thick  shrivelled  sacs 
unfurnished  with  bloodvessels, — in  stratiform  deposits  within  arteries. 
It  is  even  very  commonly  met  with  at  the  centre  of  the  said  formations, 
and  therefore  at  the  greatest  distance  from  vascularized  parts ;  as,  for 
instance,  in  the  coagula,  within  the  vascular  system,  in  tubercule- 
granules,  and  in  crude  fibre  in  circumscript  masses. 

(c.)  Lastly,  by  the  appearance  of  fats  in  the  said  formations  being  the 
forerunner  of  their  entire  metamorphosis,  and  generally  speaking  of  their 
destruction. 

For  this  adventitious  production  of  fat,  more  especially  as  it  affects  a 
blastema  in  the  progress  of  development,  or  even  perfected  textures,  we 
find  the  term  fatty  disease  or  degeneration,  peculiarly  appropriate  ;  and 
we  consider  it  to  be  fraught  with  quite  enough  of  interest  for  general 
pathology,  to  justify  an  attempt  to  enumerate  here  the  various  phases 
of  its  occurrence. 

1.  Appearance  of  fat  in  the  blood  [or  fibrin]  coagula  in  veins, — the 


158  FAT-TEXTURES. 

« 

result  of  blood  disease,  either  spontaneous,  or  consequent  upon  infection 
by  inflammatory  products. 

2.  The  fatty  conversion  of  coagula  development  through  similar  agency, 
in  the  capillary  system,  as  so-called  depots — metastases. 

3.  In  fibrinous  and  albuminous  products  of  inflammation, — exudates, 
and  especially  pus.     This  is  manifest  in  the  exudates  of  serous  mem- 
branes. 

4.  In  the  albuminous,  fibrino-albuminous  products  of  Bright's  disease 
of  the  kidney.     The  spots  involved  in  the  process  of  fatty  conversion 
are  cognizable  to  the  naked  eye  as  dullish  white,  glistening,  for  the  most 
part  somewhat  turgescent  points. 

5.  In  lardaceous  infiltration  of  the  liver.     The  lard-like  blastema  is 
seen  here  and  there  opaque, — of  a  dull  white  or  whitish-yellow. 

6.  In  tubercle,  in  incipient  softening  of  the  latter,  and  in  like  manner 
in  crude  fibrinous  deposits. 

7.  In  colloid,  as  met  with  frequently  in  the  thyroid  gland.     In  colloid 
of  the  more   consistent  kind,   it  is  discernible  with  the  naked  eye  as 
opaque,  dull-white  or  whitish-yellow  spots. 

8.  In  cancers,  where  it  enters  into  emulsion-like  combinations  with 
albumen,  as  also  into  saponaceous,  glutinous  conjunctions  with  bases — 
saponification  of  cancers.     The  points  de  depart  are  here  the  yellow, 
fibrinous  masses  which  either  traverse  tha  cancer  as  a  so-called  reticulum, 
or  else  occur  as  circumscript  accumulations. 

9.  In  atheromatous  disease,  in  the  strata  that  form  upon  the  inner 
surface  of  arteries,  and  in  the  soft  matrix  of  phlebolites. 

10.  In  the  fibroid  blastema  and  texture,  more  especially  of  fibroid 
tumors  and  exudates. 

11.  In  the  annulo-fibrous  tunic  of  arteries,  where  it  occurs,  either 
pure  or  combined  with,   and  dependent  upon,  stratiform  deposits  and 
their  metamorphoses — atheroma  and  ossification. 

12.  In  the  muscles,  especially  the  involuntary,  and  the  heart  in  parti- 
cular.    Here  we  encounter  an  obvious  conversion  of  the  muscle-fibrils  to 
molecular  fat,  with  loss  of  the  transverse  striae  and  inflation  of  the 
sheaths. 

Further  investigations  are  necessary  to  determine  whether  milky 
blood — the  peculiar  aspect  of  which  is  due  to  fat ;  and  whether  the  pel- 
let-like excretion  of  fat  from  the  intestine,  should  be  classed  along  with 
the  above. 

This  conversion  into  fat,  affects,  as  we  have  seen,  now  crude  fluid  and 
solid  blastemata,  now  such  as  have  attained  to  various  grades  of  tex- 
tural  development ;  finally  perfected  textures. 

The  form  or  type  under  which  the  conversion  takes  place  is  very  fre- 
quent, more  especially  in  fluid  blastemata.  It  has  been  described  under 
the  head  of  "  metamorphoses  of  blastemata." 

This  process  is  in  one  sense  to  be  regarded  as  a  propitious  event,  as 
reducing  certain  growths  to  a  condition  readier  for  resorption  and  for  re- 
assimilation.  Moreover,  it  determines  a  state  of  involution,  isolation, 
extinction  of  the  involved  growths. 

In  this  latter  property,  it  is  often  allied  with  ossification  and  cretefac- 
tion  of  blastemata  and  textures, — processes  offering  many  points  of 


HORNY    TEXTURES.  159 

analogy,  and  even  of  affinity  with  fatty  disease  from  the  disengagement 
of  pre-existent  fat.  We  need  only  advert  to  the  cretefaction  of  crude 
blastemata  in  the  coagula  of  the  larger  bloodvessels,  and  in  the  capillary 
system,  in  exudates,  in  pus,  in  tubercle, — to  the  ossification  and  Crete- 
faction  of  stratiform  deposits  in  the  arteries,  of  the  fibroid  textures,  &c., 
— and  compare  this  process  with  the  collateral  one  of  fatty  conversion. 

Fats,  the  product  of  conversion,  may  present  much  variety  of  cha- 
racter. In  most  instances  they  are  fluid  fats  in  a  state  of  minute 
molecular  subdivision,  in  larger,  lustrous,  strongly  refracting, — or  else, 
in  less  bright,  yellowish,  tough  globules.  In  exudates,  in  tubercle,  in 
colloid  substances,  in  cancers,  and  especially  in  the  atheroma  of  arteries, 
cholesterine  is  frequently  encountered  in  a  crystalline  state. 


8.   EPIDERMIDAL  AND   HAIR  FORMATIONS. 

The  excessive  production  over  expansive  "surfaces,  both  external  and 
internal,  of  epidermis,  with  a  normal  form  and  aggregation  of  its 
elements,  is  often  well  exemplified,  so  far  as  the  mucous  membranes  are 
concerned,  in  those  of  the  oesophagus  and  vagina.  There  are,  however, 
epidermidal  luxuriations  besides,  marked  by  several  peculiarities,  such 
as  site,  circumscribed  locality,  unusual  aggregation  of  elements.  To 
these  belong,  also,  the  epithelial  layers  investing  the  various  cysts. 

(a.)  As  epithelial  contents  of  encysted  tumors.  The  form  of  the  cells 
is  most  commonly  that  of  tessellated  epithelium  cells. 

Upon  the  external  skin  these  tumors  manifest  themselves  as  luxuriant 
new  growths,  sometimes  overspreading  a  wide  surface,  sometimes  limited 
to  a  smaller  space,  occasionally  as  cyst-like  developments  of  cutaneous 
follicles  with  their  excretory  ducts.  These  growths  not  rarely  attain  to 
a  considerable  circumference,  and  are  distinguished  by  a  peculiar 
anomalous  arrangement  of  their  elements,  as  also  by,  on  the  one  side  a 
retarded,  on  the  other  an  excessive,  horny  character  of  the  elementary 
cells. 

(5.)  Clavus,  a  local  accumulation  of  epidermis-cells,  of  a  conical  shape 
with  the  apex  pointing  to  the  interior  of  the  papillary  body,  with  a 
superimposed  disposition  of  the  cells  not  deviating  from  the  normal. 

(c.)  Warts. — Of  these  there  are  sundry  varieties.  The  most  ordinary 
consists  of  cornified  epidermis  forming  a  sheath-like  receptacle  of  con- 
siderable thickness  for  the  hypertrophied  cutaneous  papillae.  Others 
are  marked  by  the  elongated  fibrous  arrangement  of  very  luxuriating 
cells,  as  polyedrical,  edged  cylinders  in  parallel  array,  some  of  which 
show  imperfect  cornification.  They  have  a  fibro-villous,  appearance,  are 
humid,  and  readily  broken  up  by  pressure  into  fibres  and  their  elements. 
Their  cells  are  devoid  of  nuclei,  and  in  only  a  few  instances  cornified. 

(d.)  Ichtfiyosis. — The  higher  grades  alone  concern  us  here,  the  epi- 
dermis covering  a  papillary  body,  proportionately  hypertrophied,  luxu- 
riates into  polyedrical  tessellae,  cylinders,  and  disks.  The  disposition 
of  the  cells,  at  least  in  the  cylinder  form,  is  a  fibrous  one,  parallel  to 
its  length.  The  degree  of  cornification  is  not  in  every  case  the  same. 

(e.)  Horn — cornu  cutaneum — a  very  common,  for  the  most  part  dingy- 


160  PIGMENT    FORMATION. 

brown,  longitudinally  ribbed,  more  or  less  curved,  cylindrical  or  conical 
horn-growth,  springing  from  a  cutaneous  follicle  of  cyst-like  develop- 
ment. It  attains  now  and  then  to  several  inches  in  length.  Its  structure 
is  seemingly  fibrous.  The  cornification  of  the  cells  is  very  marked.  It 
affects  parts  abounding  in  follicles,  or  hairy  surfaces  and  their  vicinity ; 
for  example,  the  forehead,  the  neighborhood  of  the  pubes,  and  again,  the 
back  and  the  upper  extremities. 

All  these  growths  are  in  their  nature  innocent. 

Besides  these,  however,  there  occur  upon  the  common  integuments,  as 
also  upon  the  mucous  membranes,  growths  which,  although  often  extir- 
pated with  a  favorable  result,  occasionally  prove  malignant  and  assimi- 
late in  all  respects  to  cancer.  Their  elementary  cells  repeat  the  form  of 
the  non-cornified,  nucleated,  tessellated  epithelium-cell,  not  rarely  with  a 
fibre-like  prolongation,  and  whose  secondary  arrangement  often  displays 
the  areolar  type,  or  else  represents  in  fibrils  a  moist  velvety  growth, 
similar  to  hypertrophied  cutaneous  papillae. 

Anomalous  hair  occurs  in  various  shapes  with  reference  to  the  form, 
color,  length,  and  thickness  of  the  hair-cylinder. 

Besides  their  appearance  at  unusual  points  of  the  external  integu- 
ments, especially  upon  pigment  nsevi,  we  have  to  advert  to — 

(a.)  Hair  contained  within  encysted  tumors.  This  is  commonly 
mingled  with  fat  and  epithelium.  It  is  extremely  frequent  in  the  fatty 
cysts  of  the  ovaries,  but  is  also  found  in  those  of  the  omentum,  of  the 
cutis,  of  the  subcutaneous  areolar  tissue,  and  even  of  the  lungs.  In  these 
cysts  it  is  often  found  to  pervade  the  fat,  as  with  a  felt  growing  out  of 
variously-sized  patches,  closely  resembling  the  cutaneous  texture,  from 
the  inner  surface  of  the  sac.  Its  development  is  here  seen  to  be  entirely 
identical  with  that  of  hair  upon  the  common  integuments. 

(b.)  Hair  upon  mucous  membranes.  It  has  been  detected  upon  various 
mucous  membranes,  including  even  the  conjunctiva  of  the  eye. 

Very  small,  partly  microscopical,  hairs  are  sometimes  mixed  up  with 
the  contents  of  encysted  tumors, — with  cholesteatoma.  Those  said  to 
occur  in  the  different  secretions,  the  urine  for  example,  are  evidently 
derived  from  a  mucous  membrane. 

9.    PIGMENT   FORMATION. 

Irrespectively  of  all  other  anomalous  coloration,  but  with  a  retrospect 
to  that  conversion  of  blood-pigment  alluded  to  under  the  head  of  hemor- 
rhage, we  shall  here  treat  of  granular  pigment.  It  appears  under 
the  various  shades  of  jet,  of  Indian-ink  black,  of  russet,  or  of  a  yellow- 
brown. 

It  occurs  both  free  and  enclosed  within  cells,  in  the  shape  of  very 
small,  spheroidal,  scattered  or  clustered  granules,  together  with  rod-like 
molecules  (with  molecular  motion),  or  else  in  the  shape  of  larger  spheri- 
cal or  spheroidal,  in  like  manner  either  scattered  or  intimately  grouped 
and  blended  corpuscles.  The  cells  are  for  the  most  part  spherical,  but 
in  certain  conditions,  as  in  cancer  melanodes,  spindle-shaped,  caudate, 
rarely  twigged. 

These  various  modes  of  occurrence,  together  with  the  several  shades 


PIGMENT    FORMATION.  161 

of  the  pigment  enumerated,  are,  as  we  shall  afterwards  see,  partly  phases 
of  development  of  the  pigment,  partly  due  to  external  conditions. 

It  hardly  ever  occurs  quite  pure  between  the  elementary  parts  of  a 
texture.  Generally  speaking,  it  adheres  to  a  blastema  at  some  period 
of  textural  development,  for  instance,  to  inflammatory  products,  adventi- 
tious membranes,  colloid,  malignant  growths  (melanosis). 

When  small  in  quantity  and  equably  distributed,  it  determines  slate- 
gray  coloration  of  the  textures,  or  a  speckling  or  streaking  with  black 
dots.  It  may,  however,  manifest  itself  in  larger  knotty  accumulations 
so  as  to  consolidate  and  lay  waste  the  textures,  as  for  example  in  the 
lung. 

It  affects  the  fluids  also. 

Before  speaking  of  its  origin,  it  is  requisite  to  pass  in  review,  as  a 
simple  series  of  facts,  the  several  cases  of  its  occurrence. 

In  normal  textures,  the  sequence  of  its  amount  and  frequency  is  nearly 
as  follows  : 

1.  In  the  lungs,  its  seat  is  the  true  pulmonary  texture,  but  also  the 
interlobular  areolar  tissue.     When  inconsiderable  in  quantity,  it  lightly 
marbles  the  parenchyma.     WThen  abundant,  it  forms  greater,  branched 
accumulations,  and  along  with  these,  distinct  solitary  masses  of  from  a 
hempseed  to  a  bean  in  size,  and  presenting  a  cut  surface  of  dull  metallic 
lustre.     Or,  again  circumscribed  patches  of  the  parenchyma,  especially 
at  the  apex,  may  be  so  replete  with  it  as  to  display  it  as  a  coherent, 
black,  hardened,  impervious  mass.     It  is  particularly  redundant  around 
shrivelling,  cretefying  tubercles,  healing  cavities  and  cicatrices  at  the 
apices  of  the  lung.  It  is  for  the  most  part  found  pure,  free,  in  the  shape 
of  a  minute  molecule,  unattached  to  any  ostensible  blastema,  and  certainly 
very  seldom  contained  within  cells. 

In  manhood  and  old  age  it  is  but  a  physiological  product.  In  the 
earlier  periods  of  life  alone,  as  those  of  boyhood  and  youth,  or  when  by 
its  quantity  it  proves  destructive  to  the  pulmonary  texture,  is  it  to  be 
regarded  as  a  morbid  phenomenon.  The  notion  of  its  being  peculiar  to 
old  age  is  correct  only  in  so  far  as,  in  the  aged,  it  is  for  explicable 
reasons  hardly  ever  absent.  It  does  not,  however,  by  any  means  belong 
exclusively  to  this  period  of  life.  If  it  almost  invariably  abounds  in  the 
old,  it  is  because  in  them  there  has  been  ample  time  for  its  accumula- 
tion. Still  it  is  undeniable  that  the  condition  of  the  blood  in  advanced 
age,  with  its  augmented  proportion  of  blood-corpuscles,  and  its  simulta- 
neous diminution  of  fibrin,  must  essentially  favor  the  deposition  of  this 
substance. 

2.  In  the  bronchial  glands,  from  a  speckling  and  extensive  marbling 
up  to  the  point  of  considerable  increase  of  volume  in  the  gland,  and  its 
conversion  into  a  hard  Indian-ink-colored  tumor,  in  which  the  glandular 
parenchyma  has  perished.     Its  amount  is  here  commonly  proportionate 
to  that  in  the  lungs.     Its  form  is  that  of  free  molecule,  very  rarely  of 
molecule  contained  within  cells. 

3.  Gastric  and  intestinal  mucous  membrane.     In  the  shape  of  free 
molecules,  often  coherent  in  larger  masses.     It  occurs  thus  both  in  the 
muco-membranous  texture  itself,  more  particularly  at  the  great  concourse 
of  the  solitary  and  of  the  aggregate  glands,  as  also  in  the  intestinal  villi, 

VOL.  I.  11 


162  PIGMENT    FORMATION. 

imparting  to  the  raucous  membrane  an  aspect,  to  the  naked  eye,  of  being 
lightly  brushed  over  with  black,  or  uniformly  tinged  of  a  slate-gray. 
Where  the  accumulation  of  pigment  is  considerable,  the  part  appears  of 
a  blackish  gray,  or  it  may  be  of  a  deep  black. 

In  rarer  instances,  the  tracheal  and  bronchial  mucous  membrane  is 
pigmented — that  of  the  uterus  frequently. 

In  the  majority  of  cases  it  accompanies  the  more  intense  chronic 
catarrhs  (blennorrhoeae)  of  the  stomach  and  intestines.  When  aifecting 
the  intestinal  glands,  it  points  to  antecedent  hyperaemia,  stasis,  and  ex- 
udation— typhus,  for  example, — at  every  age,  even  in  delicate  children, 
to  a  diarrhoea-like  process  in  the  follicles  of  the  colon. 

4.  In  the  mesenteric  glands,  it  is  for  the  most  part  limited  in  amount, 
and  concurrent  with  pigment  in  the  intestinal  mucous  membrane.     Here, 
again,  it  is  a  sequel  to  typhous  hypersemia  and  effusion. 

In  other  lymphatic  glands,  the  seat  of  hypersemia,  hemorrhage,  inflam- 
matory stasis,  and  exudation,  it  is  less  frequent. 

5.  In  the  central  ganglia  of  the  abdominal  sympathetic,  more  espe- 
cially the  ganglion  of  the  solar  plexus,  usually  combined  with  wasting 
thereof,  as  a  sequel  to  typhous  hyperaemia.     For  the  most  part  small  in 
quantity,  has  a  uniform,   pale,   slate-gray  coloration,   or  is  visible  as 
blackish  dots  or  striae. 

6.  In  the  common  integument,  as  the  so-called  melasma  of  the  old  or 
cachectic,  as  a  diffuse  suffusion  of  the  common  integument  with  pigment, 
in  the  lower  extremities,  and  as  knotty  pigment  accumulations  in  the 
face. 

In  new  growths : 

1.  In  the  blood-coagula  in  arteries,  veins,  and  capillaries  (metastases), 
whether  spontaneous  or  due  to  inflammation  of  their  coats,  and  termi- 
nating in  their  transmutation  to  fibroid  shrivelling  cords  and  cicatrices. 

2.  In  atheroma  that  has  discharged  itself  into  the  canals  of  arteries, 
and  especially  in  the  depots  and  cicatrices  formed  in  the  act  of  its  excre- 
tion. 

3.  In  the  membranaceous  growths  investing  hemorrhagic  depots,  as 
also  in  the  contents  of  hemorrhagic  cysts,  being  here  of  a  russet  or  yeast- 
color.     The  black  pigment  found  in  the  shrivelled  and  extinct  ovarian 
follicles,  after  elimination  of  their  contents  (during  menstruation),  is  here 
deserving  of  mention. 

4.  In  inflammatory  products  upon  serous   membranes,  as  a  black 
pigment,  upon  the  peritoneum,  more  commonly  of  a  brown,  or  rust-color 
upon  the  tunica  viginalis  testis,  upon  the  pleura,  the  pericardium,  the 
arachnoid.     It  adheres  to  the  exudate  from  the  commencement,  that  is, 
from  its  crude  condition,  through  all  its  phases  of  textural  development, 
up  to  the  areolar  or  the  fibroid  structure.     According  to  its  proportion, 
it  manifests  itself  as  spotted,  striated,  or  uniformly  slate-gray,  bluish- 
black  coloration, — always  occurring  as  free  pigment  molecule. 

It  is  more  rare  in  the  inflammatory  products  of  parenchymata.  Scar- 
textures  are,  however,  not  exempt  from  it,  even  in  the  common  integu- 
ments. 

To  its  appearance  on  serous  membranes  we  have  to  add  that  detected 
upon  the  inner  membrane  of  cysts,  and  of  the  cyst-like  developments  of 


PIGMENT    FORMATION.  163 

various  hollow  organs  and  canals — for  instance,  upon  the  inner  surface 
of  the  dropsical  Fallopian  tube  sac. 

5.  In  tubercle,  that  is  to  say,  the  hemorrhagic  tubercle,  both  in  paren- 
chymata  and  upon  serous  membranes. 

6.  In  colloid, — mostly  as  a  brown  tint. 

7.  In  cancer  melanodes  (commonly  called  melanosis,  malignant  mela- 
nosis),  a  heterologous  growth,  consisting  of  medullary  carcinoma  with 
pigment.      The   brown  and  black  pigment  is  here  partly  free,  partly 
contained  in  cells,  with  the  character  of  cancer  cells.     The  medullary 
carcinoma  is  in  various  degrees  spotted  or  striated  with  the  pigment,  or, 
in  fine,  so  replete  with  it  as  to  appear  throughout  dark  brown  or  black. 
(See  Cancer  melanodes.) 

In  fluids : 

1.  In  the  fluid  portion  of  the  exudate  in  serous  sacs. 

2.  Mingled  with  the  contents  of  the  larger  cysts,  and  of  hollow 
organs  in  process  of  cyst-like  development ;  for  example,  the  dropsical 
tube-sac. 

Finally,  it  occurs  under  several  special  conditions,  as : 

1.  In  the  black  substance  present  in  acute  softening  of  the  stomach ; 
in  the  black  contents  of  the  stomach  and  intestines  generally. 

2.  In  the  pulp  constituting  the  rare  black  softening  of  the  spleen. 

3.  In  the  detritus  of  necrosed  textures,  especially  in  dry  gangrene, 
or  mummification. 

4.  In  the  parietes  of  ill-conditioned  abscesses — ichor  depots;   but 
most  of  all  at  the  margin  and  base  of  every  variety  of  intestinal  ulcer. 

This  preliminary  will  serve  as  a  useful  starting-point  for  an  inquiry 
as  to  the  groundwork  of  pigment,  and  the  conditions  upon  which  its 
appearance  depends. 

That  the  groundwork  of  pigment  is  the  coloring  matter  of  the  Hood 
appears  to  us  proved,  the  cases  in  which  pigment  is  obviously  derived 
from  haematin  and  blood-corpuscles  being  so  numerous  as  to  exclude  all 
doubts  on  the  subject.  Still  the  circumstances  by  which  the  conversion 
is  brought  about,  and  still  more  the  various  shadings  of  the  pigment,  are 
unexplained. 

The  cases  in  which  the  metamorphosis  of  blood-pigment — that  is  of 
blood-corpuscles  into  pigment — is  manifest,  are  of  the  most  common 
occurrence.  Such  are  the  cases  of  hemorrhage,  and  of  hemorrhagic 
exudates  in  serous  sacs,  more  particularly  the  peritoneum,  of  hemor- 
rhage from  intestinal  ulcers,  of  pigment  development  in  blood-coagula 
within  vessels,  of  black  or  dark-colored  softening  of  the  stomach,  of 
black  contents  of  the  stomach  and  intestines  generally,  &c. 

But  hemorrhage,  whether  simple  or  combined  with  inflammatory 
exudation,  cannot,  in  all  instances,  be  assumed,  still  less  proved.  In 
the  other  cases,  therefore,  where  pigment  occurs,  for  example,  in  the 
lungs,  the  lymphatics,  &c.,  we  must,  whilst  still  holding  on  to  the  belief 
that  haematin  furnishes  the  groundwork  of  the  dye,  look  around  us  for 
some  further  mode  of  elucidating  the  mystery. 

The  pigment  may,  independently  of  any  development  out  of  extra- 
vasated  blood,  be  brought  about  through — 

1.  The  obliteration  of  small  bloodvessels  or  capillaries,  with  the  con- 


164  PIGMENT    FORMATION, 

version  to  pigment  of  their  contained  blood,  just  as  the  stain  is  pro- 
duced in  plugging  blood-clots  within  the  greater  vessels.  As  the 
vessel's  parietes  disappear  through  absorption,  striated  accumulations  of 
pigment  corresponding  to  the  course  of  the  vessel,  are  entailed  in  the 
textures.  This  takes  place  more  particularly  in  membranaceous  areolar 
tissue  formed  upon  serous  membranes  previously  vascularized.  In  these 
the  opportunity  sometimes  offers  of  tracing  the  aforesaid  process.  Even 
the  pigment  in  callosities  entailed  by  so-called  capillary  phlebitis  may 
be  partly  brought  about  by  the  same  means,  namely,  by  metamorphosis 
of  the  blood-coagulum  in  the  vessels  destroyed. 

2.  Through  conversion  to  pigment  of  the  blood  in  different  blaste- 
mata,  especially  the  products  of  inflammation  and  cancer  melanodes. 

3.  By  transformation  of  the  blood-pigment   along  with  other  sub- 
stances in  the  normal  act  of  nutrition,  or  in  consequence  of  hypersemia 
and  inflammation.     The  probability  of  this  event  will  be  relative  to  the 
predominance  of  the  blood-corpuscles  in  the  circulation  generally,  to  the 
number  of  old  and  very  highly  colored  globules  present,  and  lastly,  to 
the  extent  to  which  their  coloring  matter  is  taken  up  by  the  plasma 
when  attenuated  through  the  diminution  of  its  salts,  or  the  destruction 
of  its  fibrin.     In  this  manner  it  is  intelligible  how  pigment  may  become 
engendered  without  the  extravasation  of  blood-corpuscles,  how  it  so  often 
becomes  deposited  in  the  lungs,  as  the  central  receptacles  for  venous 
blood,  how  the  aged  are  peculiarly  prone  to  its  deposition,  and  lastly, 
how  in  certain  erases,  the  typhous  for  example,  it  so  frequently  attaches, 
as  the  residue  of  hypersemia  and  inflammation,   to  the  follicular  appa- 
ratus and  the  mesenteric  glands. 

It  would  seem  to  have  arrived  at  certain  organs  partly  through  re- 
sorption — the  bronchial  glands,  for  instance. 

Our  own  investigations  concerning  the  morphological  process  of  pig- 
ment formation  have  led  to  the  following  conclusions  : 

The  pigment  differs  according  as  its  basis  consists  of  hgematin  alone 
in  a  state  of  solution,  or  of  blood-corpuscles. 

In  effusions  reddened  by  dissolved  hsematin,  the  pigment  separates  as 
a  result  both  of  the  changes  produced  by  resorption,  by  the  accompany- 
ing menstrua,  and  by  consolidation,  and  also  of  probable  external 
agencies  effecting  coagulation  or  precipitation  in  the  shape  of  a  granular 
mass  (of  discrete  or  agglomerated  molecular  granules),  which  imparts  a 
brown,  a  yeasty,  or  black  coloration. 

Where  blood-corpuscles  are  actually  present,  either  these  become  dis- 
solved, and  the  development  of  pigment  out  of  the  coloring  matter  takes 
place  as  in  the  foregoing  case  ;  or  else  the  haematin  becomes  pigment 
within  the  blood-corpuscles,  which  thereby  become  transformed  into 
mulberry-shaped  corpuscles.  These  remain  separate,  or  cohere  in 
groups  of  two,  three,  or  four,  or  they  may  even  gather  together  into  a 
lobulated  mass.  Earlier  or  later  they  break  up  into  the  molecular  pig- 
ment-granules before  adverted  to.  Under  both  forms  and  modes  of  de- 
velopment the  pigment  is,  to  a  greater  or  less  extent,  contained  in  cells. 
Upon  this  point,  experience  has  shown  us  that — 

1.  Pre-existent  nucleated  cells  (of  various  forms)  take  up  hsematin, 
which,  as  the  contents  of  the  cells,  becomes  molecular  pigment.  This 


PIGMENT     FORMATION.  165 

is,  perhaps,  a  repetition  of  the  process  that  takes  place  in  normal  pig- 
ment formation. 

2.  One  or  more  mutually  coherent  blood-corpuscles  constitute,  as  it 
were,   a  nucleus-formation,  around  which  a   cell-wall  developes  itself. 
Even  within  this  cell  the  nucleus-mass  may  break  up  into  molecular  pig- 
ment.    The  haematin  frequently  associates  itself,  dissolved,  to  the  cell's 
contents,   and  there  coagulates  to  molecular  pigment,  whilst  the  now 
colorless  nucleus-mass  (blood-globules)  undergoes,  probably  in  its  protein 
contents  (globulin),  conversion  into  fat-globules. 

3.  A  cell-wall  forms  around  a  conglomeration  of  molecular  granules. 
These  are  frequently  all  concurrent  processes,  just  as  happens  with 

pigment  formation  external  to  cells.  The  two  former  processes  are, 
however,  both  attested  in  colored  exudates,  and  most  particularly  in 
cancer  rnelanodes.  In  either  way,  a  sort  of  pigment  granule-cell  is 
brought  about. 

The  precise  manner  in  which  the  conversion  of  haematin  to  pigment 
takes  place,  is  obscure,  if  not  altogether  unknown.  It  cannot  be  doubted 
that  the  haeinatin  undergoes  various  and  considerable  changes.  Some 
indications  in  point  are  seemingly  derived  from  the  conversion  of  hsema- 
tin  into  pigment,  through  the  palpable  influence  of  chemical  agents,  ad- 
dressed, sometimes  to  the  haematin  itself,  sometimes  to  the  iron  it 
contains.  Strong  mineral  acids  (sulphuric,  for  instance)  introduced 
from  without  darken  or  blacken  the  blood  with  which  they  come  in  con- 
tact. Carbonic  acid  gas  (evolved,  along  with  carbonic  oxide  gas,  out  of 
glowing  charcoal)  acts  in  the  same  manner  upon  the  capillaries  when  a 
stream  of  it  traverses  the  fauces ;  and  a  similar  influence  is  exercised  by 
acid  secretions  generated  in  the  organism  itself,  as  we  have  seen  in 
alluding  to  colored  softening  of  the  stomach. 

Like  the  blood  itself,  the  kindred  spleen-pulp  (spleen-corpuscles)  suf- 
fers the  same  transformation  of  its  elements.  The  change  of  color  is 
here  most  probably  determined  through  the  combination  of  haematin 
with  different  acids,  carburet,  chloride  of  haematin,  &c. 

The  very  frequent  conversion  of  red  hemorrhagic  exudates  upon  the 
peritoneum  into  black  strata,  is  most  probably  founded  upon  the  influ- 
ence of  the  intestinal  gases  upon  the  haematin.  In  common  with  ammo- 
niacal  gas,  it  is  principally  the  sulphuretted  hydrogen  of  the  bowel 
which,  acting  (by  exosmosis)  upon  the  iron  of  the  haematin,  enters  with 
it  into  a  black  combination,  namely,  sulphuret  of  iron.  A  similar  effect 
is  wrought  by  phosphuretted  hydrogen  in  abscess  and  gangrene. 

Fertile  in  results  as  are  the  above  anatomical  data  relative  to  the  fun- 
damental principle  of  pigment,  they  seem  to  throw  very  little  light  upon 
the  chemical  processes  by  which  the  conversion  of  haematin  is  regulated. 
The  influences  adverted  to  under  which  haematin  blackens,  admit  of  no 
ulterior  application.  We  are  still  reduced  to  the  entailed  general  view 
of  defective  decarbonization  of  the  blood,  to  which  the  abundance  of 
carbon  detected  by  analysis  in  the  various  black  substances,  certainly 
adds  weight. 

But  even  should  the  pigment,  as  Guillot  affirms,  of  the  black  pulmo- 
nary artery,  consist  of  pure  carbon,  this  would  in  nowise  refute  our 
theory,  namely,  that  it  is  invariably  developed  out  of  haematin. 


166  COLLOID. 

Although  russet-  and  yeast-colored  pigment  are  obviously  derived 
from  the  same  uniform  base  with  black  pigment,  yet  the  conditions  upon 
which  the  existence  of  this  pigment  depends  are  little  known,  and  its 
composition  still  less.  Thus  much  is  certain,  namely,  that  in  color  it  is 
susceptible  both  of  deepening  into  blackness,  and  of  fading  into  pale- 
ness. 

Generally  speaking,  an  organ  is  liable  to  become  the  seat  of  pigment 
formation  proportionately  to  its  vascularity,  to  its  proneness  to  hyper- 
semia,  inflammation,  and  hemorrhage,  and  to  the  extent  to  which  its 
blood-supply  is  marked  by  excess  of  coloring  matter,  that  is,  by  the 
venous  character  (Venositat). 

The  resorption  of  granular  pigment  is  a  fact !  How  this  takes  place, 
— how  and  whereby  it  becomes  adapted  for  the  process,  is  not  known. 

In  itself  pigment  is  an  innocent  new  growth. 

It  is  still  of  some  importance  to  inquire  what  is  to  be  thought  of  the 
distinction  of  pigment  into  true  and  false  melanosis.  Seeing  that  pig- 
ment has,  under  all  circumstances,  one  and  the  same  fundamental 
principle  (hsematin),  and  that  our  knowledge  of  its  workings  is  limited, 
the  distinction  seems  supererogatory.  Which  is  the  true  and  which  the 
false  ? 

We  deem  it  most  advisable  to  abolish  the  word  melanosis  altogether, 
and  to  substitute  for  it  the  term  pigm»nt,  designating  all  growths, 
normal  or  pathological,  into  whose  composition  pigment  enters,  as  pig- 
ment-holding or  pigmental,  and  what  has  been  called  malignant 
melanosis,  as  pigmental  cancer,  or  cancer  melanodes. 

10.  COLLOID. 

Colloid,  colloid  substance,  is  a  sufficiently  common  heterologous  for- 
mation. It  is  requisite,  however,  to  state,  that  under  this  term  sub- 
stances have  been  brought  together  which,  in  a  physical  and  chemical 
respect,  are  not  perfectly  uniform ;  for  instance,  the  colloid  of  the 
thyroid  gland,  the  substance  of  collonema,  on  the  one  side,  and  on  the 
other,  gelatinous  cancer.  Further  inquiry  may,  however,  show  such 
differences  to  be  but  modifications  and  gradations  of  the  same  substance. 

Moreover,  the  occurrence  of  colloid  abuts  so  closely  upon  the  physio- 
logical, that  it  is  difficult  to  define  its  pathological  significance.  Thus, 
it  accompanies  the  often  mere  passing  development  of  the  thyroid  gland, 
the  secretion  of  certain  follicles  undergoing  occasional  cyst-like  develop- 
ment, especially  at  the  cervix  uteri ;  and  again  it  forms  the  contents  of 
glandular  growths  in  the  progress  of  cyst-like  dilatation.  In  other  in- 
stances the  appearance  of  colloid  is  too  obviously  of  pathological  import 
to  admit  of  any  doubt.  It  constitutes  both  innocent  and  malignant  new 
growths. 

Colloid  is  a  semi-fluid  adhesive  substance,  resembling  a  saturated  solu- 
tion of  gum  or  glue,  or  a  fruit  jelly.  It  is  seldom  colorless,  ordinarily 
of  a  honey  or  pale  wine-color,  but  often  brown,  or  green,  sometimes 
black.  With  all  these  tints  it  is  clear  and  pellucid,  and  only  now  and 
then  turbid,  flocculent.  Microscopically  examined,  it  displays,  in 
smaller  or  greater  number,  elementary  granules,  nucleated  forms,  nucle- 


COLLOID.  167 

ated  and  non-nucleated  cells,  together  with  parent-cells,  in  rare  in- 
stances (even  in  colloid  of  the  thyroid  gland)  the  pouch-like  formations 
mentioned  under  the  head  of  metamorphosis  of  blastemata,  and  even 
caudate  cells. 

With  respect  to  chemical  composition,  the  reactions  are  those  of 
various  gradations  of  casein,  of  pyin,  of  certain  kinds  of  mucus. 

Colloid  is,  for  the  most  part,  found  accumulated  in  hollow  organs,  in 
follicular,  alveolar,  cystoid  spaces,  and  so  seldom  free  within  a  texture, 
that  the  former  mode  of  its  occurrence  has  been  regarded  as  pathogno- 
monic  of  its  true  character. 

1.  It  is  most  frequently  met  with  in  the  thyroid  gland,  so  frequently, 
indeed,  that  few  thyroid  glands  are  examined  in  which  more  or  less  of 
it  is  not  here  and  there  detected.     It  is  accumulated  in  the  cyst-like 
dilatations  of  already  existing  acini,  as  well  as  in  others  of  new  growth. 
The  disease  represents  lymphatic,  and  in  further  development,  cystic 
goitre.     It  occurs,  moreover — 

2.  In  simple  cysts  (whether  new  growths  or  morbid  developments  of 
pre-existent  hollow  organs,  for  example,  cysts  of  the  kidneys  consecu- 
tive to  Bright's  disease),  and  also  in  compound  cystoids, — of  the  ovary, 
for  instance. 

3.  In  the  pituitary  gland,  as  a  pale  amber-colored  layer  interposed 
between  its  two  lobes,  believed  by  Wenzel  to  be  the  cause  of  epilepsy. 

4.  In  serous  sacs,  as  a  remarkable  transformation  of  a  fibro-croupous 
exudate  into  colloid.     Andral  has  witnessed  this  in  a  pleural,  and  we 
ourselves  in  peritoneal  exudates. 

5.  A  colloid  substance  constitutes  collonema,  and  its  kindred,  benign, 
new  growths.     (See  Sarcoma.) 

6.  A  colloid  resembling  the  vitreous  secretion  of  mucous  follicles  forms 
the  contents  of  alveoli,  and  of  their  endogenous  cysts,  in  innocent  and 
malignant  new  growths, — sarcomata  and  cancers,  especially  true  alveolar 
cancer. 

A  question  of  great  interest  is,  whether  colloid  is  secreted  as  such. 

(a.)  Several  facts,  especially  the  appearance  of  colloid  in  the  Mal- 
pighian  bodies  of  the  kidneys,  but  likewise  the  transformation  of  the 
aforesaid  exudates  into  colloid,  afford  conclusive  evidence  that,  under 
some  unascertained  conditions,  albumen  and  fibrin  become  converted 
into  colloid. 

(b.)  Other  facts  render  it  probable  that  it  is  the  product  of  an  altered 
function  of  secreting  gland-cells,  or  of  the  action  of  anomalous  cells, 
parent-cells,  aveoli,  and  cysts. 

(<?.)  The  colloid  of  the  thyroid  gland  in  its  voluminous  occurrence,  as 
endemic  goitre,  merits  an  attentive  consideration  on  account  of  its  cha- 
racter of  exclusiveness  in  relation  to  tuberculosis.  The  alienated  habit 
of  body  acquired  in  endemic  goitre,  may,  indeed,  be  indicative  of  a 
change  in  the  crasis ;  although  as  to  the  nature  of  such  change,  its  rela- 
tion to  the  function  of  the  thyroid  gland,  and  its  character  of  antagonism 
with  tuberculosis,  we  are  altogether  in  the  dark. 

Colloid  undergoes  many  spontaneous  changes.  Besides  its  resorption, 
as  observed  in  colloid  of  the  thyroid  gland,  it  becomes,  in  cyst,  diluted 
by  the  thin  secretion  from  the  cyst-wall,  or  else,  under  gradual  extinc- 


168  CYST. 

tion  of  the  cyst,  condensed,  and  eventually  changed  into  a  brittle  sub- 
stance resembling  dried  glue.  Lastly,  it  achieves — 

(a.)  A  remarkable  conversion  to  molecular  fat,  becoming  yellowish, 
turbid,  opaque,  and  unctuous  (colloid  of  the  thyroid  gland,  gelatin  of 
alveolar  cancer). 

(6.)  In  a  few  instances,  cretefaction, — in  colloid  of  the  thyroid  gland. 
These  cases  are,  however,  quite  distinct  from  the  cretefaction  and  ossi- 
fication of  fibrinous  exudates  within  the  strumous  thyroid  gland. 

11.    CYST  AND   ALVEOLUS. 

In  asserting  cyst  to  be  a  substantive  new  growth,  with  a  distinctive 
elementary  groundwork,  we  exclude  all  accidental  cyst  formations,  that 
is,  capsules  and  sheaths  forming  around  foreign  bodies,  extravasate,  or 
entozoa  (cysticercus,  for  example) ;  as  also  cyst-like  disease  of  hollow 
organs  consequent  upon  the  closing  and  obliteration  of  their  excretory 
ducts  and  orifices, — for  example,  in  the  gall-bladder,  the  Fallopian  tube 
and  uterus,  the  vermiform  appendix,  the  sebaceous  and  muciparous 
glands.  Certain  gland-elements,  however,  and  in  particular  those  of  the 
thyroid  gland,  demand  an  especial  consideration,  inasmuch  as  these 
hollow  bodies  represent  a  certain  stage  in  the  process  of  cyst  formation, 
having  the  same  elementary  structure,  an&  being  susceptible  of  ulterior 
cyst-like  development. 

Let  us  begin  with  the  results  of  an  examination  with  the  naked  eye  of 
perfect  cysts,  and  in  particular  of  the  exquisite  specimens  so  frequently 
met  with  in  the  ovaries. 

We  have  the  simple  (unicancellated)  and  the  compound  cyst  (Muller's 
compound  cystoid).  The  first  is  sufficiently  characterized  by  its  name. 
Compound  cysts  declare  themselves  by  phenomena  which  induced 
Hodgkin  to  distinguish  them  in  two  classes,  although  types  of  both 
very  commonly  coexist  in  the  same  formation.  The  first  comprehends 
a  cyst-formation  with  cysts  of  a  secondary  order  in  the  parietes  of  a  volu- 
minous (parent)  cyst ;  and  these  secondary  cysts  involve,  in  like  manner, 
cysts  of  a  tertiary  order  within  their  parietes.  These  filial  cysts  project 
upon  the  outer  surface  of  the  parent  cyst,  rather  than  upon  its  inner 
surface,  where  they  are  in  a  degree  flattened.  The  wall  of  the  parent 
cyst  often  appears  separated,  receiving  the  secondary  cyst,  as  it  were,  in 
a  chink. 

Such  a  formation  is  to  be  distinguished  from  a  group  of  simple  cysts 
developed  in  mutual  juxtaposition,  some  one  of  which  predominating  in 
size,  flattens  the  contiguous  smaller  ones.  A  group  of  smaller  cysts  in 
an  ovary  may  readily  mislead  ;  making  it  seem  as  if  the  fibrous  capsule 
of  the  ovary  were  but  the  wall  of  a  cyst,  and  as  if  the  smaller  cysts 
interposed  between  it  and  a  contiguous  larger  one,  were  secondary 
cysts. 

The  repetition  of  this  process  of  secondary  cyst-formation  frequently 
leads  to  a  very  complex  cyst-formation,  wherein,  however,  for  the  most 
part,  a  cyst  pre-eminent  in  size,  reveals  itself  as  the  parent  or  primary 
cyst  in  whose  parietes  the  cysts  of  the  second  order  become  developed. 
Sometimes  the  primary  cyst  is  so  prolific  of  this  secondary  cyst  deve- 


CYST.  169 

lopment  within  its  parietes,  as  to  endow  the  latter  with  a  considerable 
thickness.  It  may  even  cause  them  here  and  there  to  degenerate  into 
a  tumor,  consisting  of  an  aggregate  of  cysts,  collocated  like  facetted 
pouches  in  the  breadth  of  the  cyst-wall,  and  presenting  a  polyedrical 
cell-structure,  in  and  upon  the  walls  of  which  smaller  cysts  arise.  Occa- 
sionally a  cyst-wall,  so  constituted,  further  degenerates  (owing  to  a  rup- 
ture of  the  secondary  cysts,  and  to  their  bursting  into  the  cavity  of  the 
parent  cysts)  into  a  multilocular  cell  or  network. 

Every  cyst  is  of  course  competent  to  represent  a  parent  cyst  in  rela- 
tion to  its  own  ulterior  cyst  production. 

The  second  category  comprises  cysts  in  which  secondary  cysts  arise 
upon  the  internal  surface  of  the  parent  cyst,  and  grow  into  its  cavity. 
They  are  sessile  upon  a  broad  base,  or  more  often  upon  a  neck  or  pedi- 
cle ;  in  which  case  they  mostly  represent  pear-  or  wedge-shaped  tumors. 
They  often  so  luxuriate  in  number,  and  at  the  same  time  grow  to  such  a 
size  as  nearly  to  fill  a  parent  cyst  of  considerable  magnitude.  In  rare 
instances,  a  solitary  cyst  of  this  kind  so  increases  as  singly  to  fill  up  the 
space  of  the  parent  cyst,  causing  the  sac  to  consist,  down  to  the  base  of 
the  filial  cyst,  of  two  contiguous  layers. 

These  secondary  cysts  become  developed  in  the  internal  layer  of  the 
parietes  of  the  parent  cyst,  and  have  a  sheath  derived  from  the  internal 
membrane,  from  which  the  secondary  cyst  can,  with  care,  be  separated. 
In  the  pedunculated,  pear-shaped  cysts,  it  furnishes,  in  a  state  of  involu- 
tion, the  pedicle  into  which  the  pouch,  or  wedge-like  cyst,  projects  with 
a  conical  tapering  end. 

They  are  either  simple  or  compound,  according  to  one  or  other  type. 
In  their  wall,  namely,  reside  cysts  of  an  ulterior,  that  is,  a  tertiary  for- 
mation, which  grow  more  or  less  outwardly  or  inwardly ;  the  former 
acquiring  a  shallow-lobed,  blackberry-shape,  and  appearing  cellular 
within.  The  pear-shaped  cysts  commonly  consist  of  several  parallel 
pouches  of  various  lengths.  Along  with  these  are  found,  on  the  inner 
surface  of  the  parent  cyst,  in  varying  numbers,  the  smallest  vesicles, 
just  cognizable  with  the  naked  eye.  In  one  instance  these  were  found 
on  the  inner  surface  of  an  extensive  ovarian  cyst,  mixed  up  with,  for 
the  most  part,  naked  yellowish  incrustations  the  size  of  a  poppy-  or  a 
millet-seed. 

The  difference  between  these  two  types  of  the  compound  cyst  is  ob- 
viously not  essential,  but  depends  only  upon  the  seat  of  development  of 
the  secondary  cyst.  Hence,  the  very  common  concurrence  of  the  two 
types. 

There  also  occur,  on  the  inner  surface  of  the  cysts,  both  parent  and 
secondary,  ramified  cauliflower  excrescences,  flattened,  or  fungoid,  or 
pedunculated.  These  are  scattered  singly,  or  grouped  together,  or 
knotted  in  masses.  Sometimes  they  luxuriate  in  and  by  the  side  of  the 
said  secondary  cysts,  to  such  an  extent  as  to  fill  both  these  and  the 
parent  cyst,  rupturing  the  latter,  and,  in  the  frequent  cases  of  ovarian 
cyst,  invading  the  peritoneal  cavity.  In  the  ruptured  secondary  cysts 
we  often  recognize  their  sheaths  folded  back,  and  reflected  over  the 
cauliflower  vegetation. 


170  CYST. 

Besides  the  variations  alluded  to,  there  is  much  that  is  worthy  of  note 
in  and  about  these  excrescences. 

1.  They  consist  of  a  very  delicate  membranaceous  growth  folded  and 
rolled  up  in  their  pedicle,  projecting  about  and  especially  above  it  in 
various  ways,  branching  out  into  numerous  villous  and  bulb-like  pro- 
cesses, or  into  the  semblance  of  a  plaited  frill.     Upon  the  said  processes 
are  again  seated  delicate  villous  flocculi.     They  are  highly  vascular,  and 
have  a  blood-loaded  aspect. 

2.  Here  and  there  they  frequently  carry,  especially  at  the  extremity 
of  their  branchlets,  a  just  cognizable,  poppy-seed-sized,  limpid,  or  semi- 
opaque  vesicle,  or  a  hemp-seed-,  or  a  pea-  or  bean-sized  cyst. 

3.  More  frequently  still  they  bear  upon  their  twigs  solid,  though  soft, 
whitish,  roundish,  or,  from  mutual  compression,  indistinctly  facetted 
corpuscles  ;  or  else  tougher,  white,  opaque  tubercula,  mostly  of  the  big- 
ness of  millet  or  hemp-seeds.     Here  the  entire  excrescence  is  commonly 
white,  the   small  broad-based  ones  resembling  delicate  stellar  horny 
warts,  whilst  -the  larger  and  more  extensively  clustered  ones  constitute 
an  unyielding  tumor,  superficially  stellate,  studded  with  the  aforesaid 
tubercula  upon  its  peripheral  villous  structure,  permeated  throughout  its 
cut  surface  by  fibrous  threads  (the  pedicles).     In  this  tumor,  the  blood- 
vessels have  become  destroyed. 

4.  Besides  the  more  extensive  excrescences,  smaller  ones  are  com- 
monly seen,  resembling  a  nap  of  extremely  delicate  villi,  or  of  finely 
pedunculated  tubercula. 

5.  At  the  same  time  the  internal  investment  of  the  cyst  has,  in  ex- 
panded parts,  often  a  very  finely  reticulated  aspect ;  or  it  reveals  very 
minute  fissure-like  grooves,  not  a  few  of  which  are  surrounded  by  an 
elevated  ridge-like  brink.     Out  of  these  is  here  and  there  seen  to  rise  a 
simple  or  branched  excrescence.     In  other  places,  the  internal  layer  of 
the  cyst-wall  is  seen  raised  into  a  flattened  vesicle,  which,  like  the  said 
grooves,  often  displays  minute  fissured  openings.     Internally  is  some- 
times plainly  discerned  a  convoluted  mass  of  bulb-shaped  excrescences, 
or  else  a  very  minute  network. 

With  these  are  associated  larger  vesicles,  rising  into  pedunculated 
wedge-shaped  pouches,  which  contain  a  very  delicate  cancellated  struc- 
ture, and  frequently  exhibit  roundish  or  angular  chink-like  openings,  out 
of  which  delicate  felt-like  excrescences  occasionally  project.  The  size 
of  the  cysts  varies  greatly  from  that  of  a  just  cognizable  vesicle  to  that 
of  a  sac  of  from  1  to  2  lines  in  diameter.  The  compound  cysts  may,  of 
course,  attain  to  a  very  considerable  magnitude,  a  notable  portion  always 
appertaining  to  the  parent  cyst. 

The  free  space  of  the  cysts  hitherto  described,  is  commonly  occupied 
by  a  serous  synovia-like,  or  a  thicker  glutinous,  or  glutino-lardaceous, 
so  termed,  colloid  moisture. 

Examined  under  the  microscope,  the  following  additional  light  is 
thrown  upon  the  above  appearances. 

The  cyst-wall  consists  of  densely-reticulated  areolar  tissue,  the  in- 
ternal layer  constituting  an  epithelium  of  cells  or  nuclei.  In  large  cysts 
this  is,  for  the  most  part,  absent,  and  the  internal  layer  generally  pre- 
sents a  nucleated,  structureless,  or  striated  blastema,  at  the  circumfe- 


CYST.  171 

rence  of  which  the  oval  nuclei  are  in  the  act  of  splitting  into  fibres,  in 
the  direction  of  their  long  axis.  On  examining  a  section  of  the  internal 
layer  of  a  cyst-wall,  from  a  part  furnished  with  vesicles  (secondary 
cysts),  we  obtain  a  view  like  that  presented  by  the  cortical  substance  of 
a  kidney  affected  with  cyst-formation,  to  the  consideration  of  which  we 
shall  shortly  have  to  recur.  The  same  nidus  often  contains  concur- 
rently incrustations,  in  some  instances  remarkable  for  their  size  and 
figure.  On  examination,  the  excrescence  appears  as  a  hollow  growth, 
consisting  of  a  transparent  structureless  membrane,  studded  with  round 
or  oval  nuclei,  often  striated,  especially  at  the  pedicle,  and  breaking  up 
into  delicate  fibrils,  with  numerous  spheroid  protuberances.  These  be- 
come developed  into  pouches,  mostly  bulb-shaped  at  the  extremity,  and 
by  throwing  out  secondary  protuberances  and  pouches,  complete  the 
branchlets  and  twigs  of  the  excrescence.  They  may  be  invested  with 
the  epithelium  of  the  cyst-wall,  or  even  uninvested.  They  are  furnished 
with  conspicuous  bloodvessels,  which,  running  along  the  protuberances, 
describe  extensive  arches  and  anastomoses,  and  frequently  become  the 
seat  of  aneurismal  dilatations,  or  the  source  of  hemorrhagic  effusion  into 
the  cysts.  In  their  interior  they  contain  nuclei  in  various  numbers,  and 
along  with  these,  especially  near  the  blind  extremity  of  the  branchlets, 
growths  which  turn  out  to  be  young  cysts. 

These  young  cysts  dilate  into  those  spoken  of  as  cognizable  with  the 
naked  eye. 

The  minutest  excrescences  appear  as  simple,  smooth,  or  tuberous 
hollow  bulbs.  The  internal  layer  of  a  cyst-wall,  presenting  the  reticu- 
lated texture  described  (5),  appears,  when  magnified,  in  the  form  of 
elongated,  round,  angular,  distended  meshes,  through  which  the  simple, 
smooth  bulbs  penetrate  as  they  grow.  The  cancellated  framework, 
contained  within  the  described  vesicles,  consists  of  a  hyaline,  structure- 
less membrane,  studded  with  nuclei.  It  has  unquestionably  arisen  out 
of  the  fusion  of  several  bulbs. 

The  excrescence,  as  described  at  No.  3,  arises  through  the  develop- 
ment of  areolar  tissue  out  of  a  transparent  amply  nucleated  blastema. 
In  its  cavity  are  lodged,  sometimes  in  vast  quantities,  simple  and  lami- 
nated, semi-opaque,  incrusted  growths,  from  the  size  of  an  elementary 
granule  to  a  diameter  of  35  th  of  a  millimetre,  the  circumference,  most 
common  to  incrusted  cysts. 

The  excrescence  simultaneously  becomes  fibrous,  and  shrivels,  with 
condensation  of  fibrous  parts,  into  the  solid  masses  above  described. 

In  these  observations,  two  phenomena  engross  our  attention,  namely, 
the  development  of  the  secondary  cyst  and  the  hollow  growths  forming 
upon  the  internal  wall  of  the  cyst.  We  have  made  them  the  subject  of 
an  extended  investigation,  with  a  view  to  the  solution  of  the  double 
question  as  to  the  nature  of  elementary  germ  for  cysts,  both  primary  and 
secondary,  and  of  its  ulterior  development, — and  as  to  the  import  of  the 
said  hollow  growths. 

(a.)  The  cysts  best  adapted  for  the  inquiry,  are  young,  small,  clustered 
cysts,  just  visible  to  the  naked  eye ;  others  being  probably  present,  still 
smaller,  down  to  the  germ  itself,  out  of  which  they  spring.  The  cysts 
so  frequent  in  the  kidneys,  or  on  the  broad  ligaments,  and  on  the 


172  CYST. 

peritoneum  of  the  tubes  and  ovaries,  furnish  ample  materials  for  the 
purpose. 

1.  In  the  cortical  substance  of  the  kidneys,  especially  during  the 
decline  of  Bright's  disease,  a  luxuriating  cyst-formation  is  not  un- 
common. 

In  the  dimpled  depressions  upon  the  surface  of  atrophied,  gibbous 
kidneys,  reside  entire  nests  of  parallel-clustered,  just  discernible,  poppy- 
or  millet-seed-sized  vesicles,  imbedded  in  a  reddish-gray,  or  whitish  nidus. 
Occasionally  the  kidney  is  found  altogether  degraded  into  an  aggregate 
of  various-sized  cysts. 

A  small  portion  of  such  a  nidus  placed  under  the  microscope,  displays 
along  with  the  ddbris  of  renal  texture, — namely,  uriniferous  tubules  and 
Malpighian  tufts,  in  a  state  of  collapse  or  involution ;  the  former  denuded 
of  their  epithelium,  and  here  and  there  replete  with  fat  molecules — 
a  multitude  of  cysts  invisible  to  the  naked  eye.  The  more  marked  have 
parietes,  consisting  of  fibres  beset  with  elongated  oval  nuclei,  which, 
more  particularly  about  the  inner  fibre  layers,  bend  round  towards  the 
circumference  of  the  cyst.  These  cysts  are  replete  with  granulated 
nuclei, — now  and  then  with  spherical  or  polyedrical  cells,  to  which,  in 
some  few,  is  superadded  a  molecular  mass,  partially  betraying  by  its 
brown  coloration  its  character  as  pigment  granules. 

In  some  cases  this  occupies  the  centre  bf  the  cyst,  where  the  nuclei 
become  indistinct  and  disappear.  In  some  cysts,  the  nuclei  (or  cells) 
are  reduced  to  an  epithelial  formation  investing  the  cyst.  In  others, 
again,  even  this  is  wanting,  and  the  sterile  cyst  is  entirely  filled  with  a 
clear,  or  semi-opaque,  viscid  humor.  They  are  of  very  various  size,  from 
a  diameter  of  \  to  J$  of  a  millimetre,  the  former  immediately  preceding 
vesicles  distinctly  cognizable  with  the  naked  eye.  Conjointly  with  these, 
are  found  cysts,  which,  with  similar  contents  and  parietes,  consisting  of 
a  structureless  transparent  membrane,  reside  in  an  equally  structureless 
stroma,  interspersed  with  oval  nuclei,  and  in  progress  of  development 
into  a  fibrillation  about  to  encircle  the  cyst. 

We  further  discern,  commonly  within  an  aggregate  of  spherical, 
nucleus-like  bodies,  growths  of  various  magnitude,  down  to  that  which 
only  just  surpasses  the  dimensions  of  the  nucleus.  These  growths  quite 
coincide  with  the  aforesaid  structureless  vesicles.  The  smallest  contain 
a  clear  moisture,  or  are  faintly  granular.  In  the  larger  ones,  a  central 
nucleus  soon  appears,  joined  by  a  second,  a  third,  a  fourth,  and  more, 
so  as  to  fill  the  equably  dilated  vesicle.  This  description  comprises  the 
history  of  the  development  of  the  cyst,  and  may,  under  favorable  cir- 
cumstances, be  found  exemplified  in  a  single  preparation.  It  is  obviously 
the  nucleus  that  grows  up  into  the  cyst;  which,  with  reference  to 
endogenous  production,  either  generates  brood  nuclei  or  else  proves 
sterile. 

Besides  the  nuclei,  there  are  seen  smaller  corpuscles  of  all  sizes,  from 
that  of  the  nucleus  down  to  that  of  the  so-called  elementary  granule, 
and  manifesting,  in  proportion  to  their  magnitude,  more  and  more  of 
the  character  of  the  nucleus.  It  is,  therefore,  at  once  to  be  stated,  that 
the  nucleus  has  arisen  out  of  the  elementary  granule  ;  and  this,  through 
spontaneous  germination, — not  through  the  agglomeration  of  several. 


CYST.  173 

Finally,  we  observe,  in  the  preparation,  concentrically  stratified  bodies, 
also,  of  different  sizes,  and  consisting  of  incapsuled  vesicles  in  varying 
number.  These  vesicles  are  themselves  sterile,  or  the  central  vesicle 
may  have  its  space  occupied  by  one  or  more  granulated  nuclei.  Some- 
times it  is  itself  represented  by  a  nucleus.  One  or  more  of  the  external 
layers  contain,  in  like  manner,  nuclei,  oval  in  shape,  and  bent  to  a 
parallel  with  the  layer.  Again,  the  layers  are  in  some  cases  slightly 
gibbous.  Incrustations  of  these  forms  are  also  present, — nay,  kidneys 
sometimes  occur,  in  which  the  cortical  substance,  otherwise  seemingly 
sound,  is  interspersed  with  them,  looking  like  yellowish,  transparent 
grains  of  sand. 

These  are  the  results  to  which  I  have  referred,  in  describing  the  com- 
pound cystoid.  A  similar  result  is  furnished  by  the  inspection  of  a 
group  of  cysts  in  the  above-mentioned  sexual  attachments  of  the  peri- 
toneum. 

2.  The  renal  preparation  at  first  sight  so  much  resembles  the  texture 
of  the  thyroid  gland,  and  more  particularly  the  goitred  thyroid  gland, 
as  to  render  it  impossible  to  discriminate  between  the  two.     Simon  has 
directed  attention  to  this  in  vol.  xxx.  of  the  '  Transactions  of  the  Medical 
and  Chirurgical  Society.'     Not  only  is  the  normal  gland-vesicle  of  the 
thyroid  gland  identical  with  a  cyst  of  corresponding  size,  but  the  de- 
velopment of  new  gland-vesicles  in  a  goitre  is  identical  with  cyst  develop- 
ment, and  again  the  preternatural  dilatation  of  the  gland-vesicle — its 
so-called  cyst-like  degeneration — identical  with  a  cyst  outgrowing  its 
microscopical  proportions.  Nay,  the  gland-vesicle  betrays  in  its  develop- 
ment the  same  anomalies  as  the  cyst  in  its  development  as  a  sterile 
vesicle,  or  as  a  laminated  cyst  in  its  degeneration  to  a  colloid  sphere, 
and  in  its  incrustation. 

3.  The  same  relations  attach  to  cyst-formation  in  mucous  membranes. 
In  those  of  the  stomach,  the  colon,  the  uterus,  a  morbid  growth  occurs, 
known  by  the  term  cell-  or  vesicle-polypus.     It  consists  of  an  aggrega- 
tion of  from  millet  or  hemp-seed  to  pea-sized  cysts,  broad-based,  but 
mostly  furnished  with  a  neck,  and  commonly  representing  the  head-like 
free  extremity  of  a  cylindrical  prolongation  of  the  mucous  membrane. 
These  cysts  are  developed  in  the  texture  of  the  mucous  membrane, 
seldom  exceed  the  aforesaid  volume,  but  burst  and  evacuate  their  viscid, 
jelly-like  contents  upon  the  surface  of  the  mucous  membrane.     Their 
fate,  beyond  this  disruption  and  violence,  I  have  been  unable  to  ascer- 
tain.    They  probably  give  place  to  new  ones.     We  may  refer  here  to 
those  bodies  suspended  by  a  pedicle  of  mucous  membrane  from  the  cervix 
uteri,  and  known  as  ovula  Nabothi.     These,  though  commonly  received 
within  the  domain  of  physiology,  in  reality  present  a  continuous  cyst- 
formation,  destroyed  from  time  to  time  by  disruption  and  evacuation. 
They  occur,  in  like  manner,  on  the  mucous  membrane  of  the  renal  pelves, 
and  of  the  ureters. 

But  I  have  repeatedly  observed  millet,  hemp,  nay  almost  pea-sized 
cysts,  in  surpassing  numbers  in  the  mucous  membrane  of  these  urinary 
conduits.  Some  of  them  contained  a  flaky,  inspissated,  colloid  moisture. 
In  one  instance,  my  attention  was  drawn  to  them,  by  the  presence  of 
little,  roundish,  naked,  colloid  pellets,  in  the  urinary  bladder. 


174  CYST. 

Just  as  in  physiological  textures,  so  also  in  pathological  parenchymata 
does  cyst-formation  occur.  For  example ;  in  the  textures  of  sarcoma 
and  carcinoma, — giving  rise  to  the  family  of  cysto-sarcomata  and  cysto- 
carcinomata.  Even  the  so-called  carcinoma  alveolar e  consists,  mainly, 
in  cyst-development. 

Cancer-cyst  varies  in  respect  to  size  from  the  microscopic,  to  the  cir- 
cumference of  the  colossal  cysts,  in  the  compound  cystoid.  The  alveoli 
of  areolar  cancer  in  particular — that  is,  the  small  cysts  constituting 
alveolar-cancer, — and  especially  the  peripheral-alveoli,  grow  into  com- 
prehensive cysts.  The  cancer-cyst  contains  a  sero-albuminous  fluid,  a 
jelly-like  (colloid)  substance,  and  frequently  cancer-parenchyma.  It  is 
nqt  a  rare  thing  to  find — imbedded  in  a  cancer,  or  independent,  and 
remote  from  a  heterologous  growth,  ascertained  by  its  volume  to  be  the 
primary  seat  of  the  cancer-production — tumors,  obviously  consisting  of 
encysted-cancer  parenchyma,  or  cancer-tubera,  which,  manifestly  en- 
veloped in  an  often  stoutish  fibrous  capsule,  are  distinguishable  at  a 
glance  from  other  uninvested  accumulations  of  the  cancerous  substance. 
Within  the  encysted  parenchyma,  again,  is  sometimes  lodged  a  smaller, 
filial  cyst. 

Upon  this  point  and  upon  the  development  of  the  cancer-cyst  micro- 
scopic inspection  throws  much  light.  The  appropriate  materials  for 
examination  are  afforded  more  especially  *by  cancer-masses,  which,  with 
or  without  the  presence  of  voluminous  cysts,  exhibit  to  the  unassisted 
eye,  minute,  limpid  vesicles,  or  else  an  aciniform,  glandular  structure. 

In  such  cancer-growths,  besides  the  ordinary  nucleated  cells,  often 
indeed  distinguished  by  their  eccentric  forms,  we  discern : 

1.  Cells  of  notable  diameter,  up  to  -g^th  of  a  millimetre,  with  a  very 
large  nucleus,  dilated  into  a  clear  vesicle,  which  approximates  to,  if  not 
touches,  the  cell-wall.     In  some  of  these  bloated  nuclei,  a  nucleus  cor- 
puscle has  become  developed  into  a  second  central  nucleus,  which,  in  its 
turn  also,  contains  nucleus-corpuscle. 

In  certain  cells  we  find  two  of  these  advanced  globular  or  mutually 
flattened  nuclei,  as  also  several  without  a  nucleus-corpuscle,  or  with  one 
which,  in  like  manner,  expands  into  a  nucleus.  Other  cells  contain, 
along  with  a  swollen  nucleus,  one  or  more  ordinary  granulated  or  trans- 
parent, spherical  or  oblong  nuclei,  besides. 

2.  Divested  nuclei,  which,  like  the  cell-included  nucleus  (cell-nucleus), 
expand  into  larger,  transparent,  structureless  vesicles.     These — 

(a.)  Remain  sterile  cysts. 

(6.)  They  give  birth  to  numerous  secondary  nuclei,  until  the  cyst  is 
replete  with  these.  Such  cysts  often  entirely  resemble  the  gland-cyst  of 
the  thyroid  and  supra-renal  glands.  Of  these  secondary  nuclei,  one  or 
more  occasionally  grow  into  a  vesicle,  which  remains  sterile,  or  fills  with 
brood-nuclei,  or  presents  phenomena  about  to  be  described. 

(c.)  A  central  nucleus-corpuscle  appears  in  the  vesicle  and  expands 
into  a  secondary  nucleus. — This  nucleus,  like  the  primitive  one,  dilates 
into  a  vesicle  in  which  a  nucleus  formation  of  the  third  order  takes 
place. 

Out  of  the  frequent  repetition  of  this  process  originate  growths  con- 
centrically laminated,  or  consisting  of  a  series  of  endogenous  vesicles, 


CYST.  175 

which  here  again  are  distinguished  by  their  proclivity  to  incrustation. 
Sometimes  there  are  developed,  in  one  of  the  secondary  vesicles,  more 
than  a  single  nucleus — for  example,  two  out  of  each,  out  of  one  only  of 
which  a  laminated  formation  may  become  developed.  In  the  latter  case, 
ordinary  brood-nuclei  are  generated  in  the  other.  The  inner  vesicle 
either  remains  sterile,  or  a  central  nucleus,  or  it  may  be  several  nuclei, 
engross  its  space.  Here,  again,  there  may  be  laminated  structures, 
springing  from  extra-centrical  nuclei. 

All  these  structures  are  lodged  within  a  parenchyma  (differing  in  com- 
position, and  in  the  fecundity  of  its  elements),  of  nuclei,  cells,  caudate- 
cells,  fibres.  These  elements  are  so  arranged  as  to  inclose  the  said 
structures  in  a  capsular  fashion,  the  cells,  and  even  the  nuclei,  lengthen- 
ing into  riband-like,  caudate  cells,  and  oblong  nuclei,  with  a  correspond- 
ing incurvation.  (Alveolar  textural  arrangement.) 

Still,  the  main  condition  for  the  growth  of  the  vesicle  is  the  presence 
of  encircling  fibres,  and  their  appropriation  to  the  fabric  of  a  resisting 
fibrous  cyst. 

The  simultaneous  evolution  of  the  brood-nuclei  of  the  vesicle  causes 
the  cyst  to  become  speedily  furnished  with  a  proper  parenchyma  cor- 
responding with  that  which  surrounds  the  cyst.  In  this  a  filial  cyst  may 
become  developed. 

The  structureless  vesicles  alluded  to  offer  many  further  points  of  in- 
terest : 

(a.)  There  is,  frequently,  a  marked  difference  in  the  contents  both  of 
the  simple  vesicles,  and  of  the  individual  layers  of  the  vesicles  succes- 
sively ingenerated.  Thus,  some  appear  clear  and  colorless,  others  of  a 
reddish  tint ;  in  others  again,  the  contents  are  denser,  pearly,  or  opaque, 
lightly  granular.  Some  contain  granules  in  various  amount,  which  show 
themselves  to  be  fat, — fatty  conversion  of  the  nuclei. 

(6.)  Of  two  intussuscepted  vesicles  the  inner  one  is  sometimes  irregu- 
larly collapsed,  wrinkled,  or  even  pretty  regularly  indented.  This  pro- 
bably results  from  a  consecutive  difference  of  density  in  the  contents  of 
the  two,  a  condensation  of  the  contents  of  the  outer  vesicle  determining 
exosmotic  effusion  of  the  thinner  contents  of  the  inner  vesicle. 

(c.)  Intussuscepted  vesicles  are,  for  the  most  part,  sterile.  Within 
their  layers,  however,  are  frequently  impacted  oblong,  curved  nuclei. 

(d.)  The  layers  are  commonly  smooth  ;  often,  however,  gibbous,  wavy, 
and  curled. 

The  development  of  these  cysts  out  of  the  nucleus,  through  growth  of 
the  latter,  is  here  demonstrable  even  in  the  naked  nucleus ;  by  growth 
of  the  celled  nucleus,  however,  it  is  placed  beyond  all  doubt.  Here 
again,  the  elementary  granule  is  cognizable,  as  the  ultimate,  funda- 
mental form ;  the  nucleus  being  obviously  and  simply  developed  by 
growth  out  of  the  so-called  nucleolus,  or  elementary  granule. 

Difficulties  might,  however,  still  arise  so  long  as  that  theory  of  cell- 
formation  obtains  which  assigns  to  the  cell  a  genesis  and  an  import 
distinct  from  those  of  the  nucleus.  If  there  be  parent  cells,  their  resem- 
blance with  the  expanding  nuclei,  both  in  form,  and  often  in  their  rela- 
tion to  chemical  agency,  might  render  it  no  easy  task  to  determine  the 
precise  nature  of  a  vesicle,  seeing  that  parent  cells  and  parent  nuclei  are 


176  CYST. 

met  with  concurrently.  In  a  laminated  structure,  it  would  be  peculiarly 
puzzling  to  have  to  decide,  whether  its  external  contour  belonged  to  a 
cell,  or  to  a  nucleus-wall. 

From  what  has  been  stated,  however,  the  existence  of  a  cancer-cyst 
certainly  may  be  inferred,  a  cyst,  namely,  developed  out  of  the  elements 
constituting  cancerous  substance,  and  productive  of  cancer  elements 
within  itself.  Not  every  cyst,  however,  concurrent  with  cancer,  is 
necessarily  of  a  cancerous  nature,  the  malignant  growth  very  possibly 
wearing  but  the  character  of  an  accidental  complication. 

In  cysto-sarcoma  the  same  relations  obtain  as  to  the  [primitive]  de- 
velopment of  the  cyst. 

/5.  As  regards  the  excrescences  occurring  upon  the  inner  surface  of 
the  cyst,  repeated  observations  have  established  the  following  facts : 

1.  Upon  mucous  membranes,  and  especially  upon  that  of  the  urinary 
bladder,  there  occurs  a  cancerous  growth  which  we  have  elsewhere 
termed  villous  cancer,  as  a  structure  pertaining  to  medullary  carcinoma, 
and  containing  within  a  villo-membranous  vascularized  stroma,  a  medul- 
lary (encephaloid)  cancer  juice.  Later  investigations  have  led  to  results 
which  induce  me  to  reopen  this  subject. 

It  consists,  as  a  walnut-  or  a  fist-sized  tumor,  of  a  multitude  of  densely 
thronged  excrescences,  which,  upon  a  cord-like,  longer  or  shorter,  pedicle 
unfold  into  delicate  membranes,  breaking  up  into  numerous  ramifica- 
tions, and  again  into  more  and  more  tender  branchlets,  wholly  overlaid 
with  delicate  villi.  Many  twigs  have  a  grape-clustered  appearance, 
their  villi  bearing  poppy  or  millet-seed-like,  clear  or  opaque,  white 
vesicles.  Larger  cysts  reside  in  the  primary  cotyledon  and  ramification. 
Many  excrescences,  again,  represent  hollow,  shut,  or  at  their  free  ex- 
tremity, wide-mouthed  pouches.  In  one  instance,  the  entire  growth 
consisted  of  polyedrical,  at  their  free  ends  for  the  most  part  wide-' 
mouthed,  pouches,  densely  beset  with  villi  at  the  brink  of  the  aperture. 
The  tumor  is  throughout  surcharged  with  a  whitish,  creamy,  medullary 
juice.  It  is  frequently  a  more  consistent  medulla-like  mass  that  fills  up 
the  cavities  of  the  growth,  which  in  this  case  acquires  considerable 
density,  and  offers  proportionate  resistance. 

The  growth  is  in  general  highly  vascular,  and  in  its  recent  state, 
turgid,  of  a  deep  purple  tint,  and  prone  to  hemorrhage.  At  the  base, 
from  whence  the  tumor  commonly  rises  with  a  neck,  we  have  found  an 
extensive  sinus  of  a  venous  kind,  upon  the  inner  surface  of  which  are 
seen  numerous  pin-puncture  and  poppy-seed-sized  orifices,  leading  to 
bloodvessels,  which  ascend  within  the  pedicles  of  the  excrescences,  and 
accompany  their  ramifications. 

In  the  vicinity  of,  or  even  remote  from,  the  heterologous  structure, 
are  smaller  groups,  or  solitary  excrescences.  These,  when  young,  are 
very  delicate,  so  as  when  under  water  to  resemble  a  fine  nap. 

Microscopic  Examination. — In  the  cream-  or  marrow-like  juice  that 
exudes  on  gentle  pressure,  are  found  variously-shaped  cells,  with  one  or 
several,  in  part  turgid,  vesicle-like  nuclei,  along  with  bare,  middle-sized, 
and  larger-sized  nuclei,  furnished  with  a  considerable  nucleus-corpuscle,  of 
which  one  especially,  was  found  large,  and  presenting  internally  a  dull 
secondary  nucleus  contour.  This  juice  resides  in  the  before-mentioned 


CYST.  177 

pouch-like  chambers.     The  excrescences  are  externally  clothed  with  an 
epithelial  layer. 

The  membranous  structure  constituting  the  excrescence  appears  as  a 
very  delicate,  transparent,  structureless,  here  and  there  striated  mem- 
brane, overstrewn  with  oblong  nuclei,  and  breaking  forth  about  the 
pedicle  into  slender  wavy  fibrils.  It  is  invested  with  a  simple  layer 
of  granulated  nuclei  for  epithelium,  which  is,  however,  frequently 
wanting. 

A  clustered  twig  appears  as  a  clavate,  hollow  structure  upon  a  deli- 
cately fibred  pedicle,  young  cysts,  as  structureless  vesicles,  occupying 
the  interior  of  the  protuberances.  Here  are  seen  two  outlines,  of  which 
the  outer  one  belongs  to  the  protuberance,  the  inner  one  to  the  young 
cyst ;  elongated  nuclei  course  along  between  the  two.  The  cyst  is  re- 
plete with  spherical  nucleolated  nuclei.  A  few  cysts  open  towards  the 
pedicle  of  the  terminal  bulb  in  which  they  are  contained. 

In  some  of  these  sacculi  are  besides  found,  in  various  numbers  up  to 
the  point  of  repletion,  fat-globules,  some  of  largish  dimensions.  These 
lend  to  the  cyst  the  white  opaque  aspect  already  referred  to. 

The  larger  millet-seed-sized  vesicles,  visible  to  the  naked  eye,  contain 
a  colorless,  tenacious  fluid  in  which  the  above-mentioned  nuclei  float. 

A  morsel  of  a  membranous  expansion  of  the  excrescence  appears, 
when  magnified  by  50  diameters,  distinctly  to  consist  of  two  layers,  and 
is  everywhere,  but  especially  at  the  summit,  overspread  with  numerous 
bulb-shaped  protuberances,  which  themselves  throw  out  secondary  pro- 
jections ;  whilst  considerable  bloodvessels  ascend  to  all.  In  the  inside 
are  here  and  there  seated  groups  of  fat-globules. 

Their  bilaminated  structure  renders  it  more  than  probable  that  the 
layers,  in  consequence  of  the  copious  production  and  accumulation  of 
^the  cancerous  elements,  separate  into  the  pouches  aforesaid,  which,  for 
the  same  reason,  give  way  at  this  free  extremity. 

In  1842,  a  urinary  bladder  was  shown  to  us  by  Hodgkin,  at  Guy's 
Hospital,  upon  the  inner  surface  of  which  were  seated  numerous  largish 
bulb-shaped  cysts,  filled  with  the  excrescences  referred  to. 

The  extensive  development  of  the  cysts  in  a  mucous  membrane  is  in 
itself  very  remarkable ;  whether,  with  the  excrescences,  they  be  of  a 
cancerous  nature  appears  uncertain.  Upon  the  mucous  membrane  of 
the  renal  pelvis  we  have  seen,  along  with  young  cysts,  some  solitary, 
others  grouped  together  in  its  parenchyma,  awl-shaped  and  bulbous, 
smooth  and  villous,  red,  vascular  excrescences.  They  were  seated,  in 
part  singly,  partly  in  collected  groups,  some  bearing  a  just  discernible 
transparent  globule  at  their  free  extremity,  which  microscopic  examina- 
tion showed  to  be  a  young  cyst. 

2.  Upon  serous  membranes,  and  the  peritoneum  in  particular,  we 
have,  in  connection  with  luxuriating  medullary  cystocarcinoma  of  the 
ovaries,  met  with  medullary  vegetations  which,  judging  from  their  ap- 
pearance and  the  arrangement  of  their  vessels,  would  seem  to  belong  to 
this  category. 

On  the  other  hand,  an  examination  of  the  preparations  in  the  Patho- 
logical Museum  of  Vienna  has  taught  us  that  the  dentritic  vegetations 
which  often  luxuriate  upon  synovial  membranes,  and  in  the  capsule  of 

VOL.  i.  12 


178  CYST. 

the  knee-joint  so  numerously  that  it  appears  invested  with  them  as  with 
a  felt,  really  appertain  to  this  class.  In  the  interior  of  the  hollow 
growths  which  constitute  them,  a  development  of  areolar  tissue  takes 
place,  just  as  in  the  cysts  of  the  vascular  plexus,  of  which  we  shall  here- 
after speak,  until  they  at  length  become  replete  with  it.  The  largish 
terminal  bulbs  of  their  stems  and  branches  are  frequently  so  flattened  as 
to  resemble  linseed  or  melon  seeds  (Majo). 

The  entire  excrescences  with  these  numerously  seated  upon  them, 
and  it  may  be  in  imbricated  order,  acquire  the  aspect  of  foliage.  In 
one  instance  we  found  them  to  contain  fat-cells,  which  explains  what 
Johannes  Muller  meant  by  lipoma  arborescens.  In  fine,  we  doubt  not 
that  they  offer  the  original  nidus  for  the  production  of  those  circular, 
smooth,  or  knotted,  facetted  cartilage  or  bone-plates,  which  occupy  the 
inner  surfaces  of  synovial  sacs,  often  attain  to  a  considerable  volume, 
and,  by  spontaneous  detachment,  become  free  bodies  within  the  capsule. 

3.  The  encysted  parenchyma  is  often  contained  free  within  the  cyst 
space  ;  sometimes,  however,  there  is  present  a  meshwork,  issuing  from 
the  inner  wall  of  the  cyst,  the  spaces  of  which  are  filled  up  with  the 
medullary  mass.  This  framework  consists  of  a  transparent  striated 
blastema,  pervaded  by  numerous  spherical  and  oblong  nuclei,  and  break- 
ing up  into  fibrils.  Simple  hollow  bulbs  shoot  up  from  its  trellises,  and 
into  its  chamberlets.  Respecting  the  development  of  this  stroma,  two 
theories  might  be  propounded  : 

(a.)  It  might  result  from  a  continuous  separation  of  the  internal  layer 
of  the  cyst-wall. 

(b.)  It  is,  however,  far  more  probable  that,  like  the  framework  of  al- 
veolar gelatinous  cancer,  or  of  the  encysted  new  growth  of  thyroid  gland 
parenchyma  in  goitre,  it  results  from  the  blending  of  the  excrescences 
concentrically  growing  from  the  inner  surface  of  the  cyst. 

Occasionally,  sharply-defined,  spheroid  cancer  tumors  occur  in  which 
no  cyst-wall  is  discoverable,  but  yet,  in  their  interior,  a  stroma  of  this 
kind.  It  is  very  probable  that  these  tumors  were  previously  encysted 
cancer-masses,  from  which  the  cyst  has,  owing  to  a  total  disruption  with 
excessive  production  of  those  excrescences,  disappeared  or  become  part 
and  parcel  of  the  stroma. 

The  repeated  examination  of  so-called  alveolar  cancer  (gelatine  cancer 
in  alveolar  form)  offers  very  interesting  results,  corroborative  of  the 
endogenous  multiplication  of  its  cysts.  Besides  the  exogenous  aug- 
mentation, there  occurs  likewise  an  endogenous  one,  the  medium  of 
which  is  offered  by  the  often-mentioned  excrescences ;  and  in  this  pro- 
cess these  become  converted  into  the  framework,  in  the  alveoli  of  which 
the  small  cysts  are  subsequently  lodged.  From  the  inner  surface  of  a 
thick-walled  follicle,  or  alveolus,  numerous  simple  bulbous  pouches  shoot 
up  into  it,  so  as  to  penetrate  it.  Another,  contiguous,  is  replete  with  a 
young  delicate  alveolar  parenchyma.  In  the  interior  of  those  hollow 
bulbs  is  seen  one,  or  a  pair  of  cysts.  In  such  prolific  cysts  the  develop- 
ment of  the  fibre-layer  for  the  young  cysts  may  often  be  seen  proceed- 
ing from  the  base  of  the  excrescences,  near  the  inner  wall  of  the  parent 
follicle.  Gluge  has  seen  these  bulbous  pouches  in  a  cancer  of  the  rec- 
tum, and  figured  them.  Owing,  however,  to  his  treatment  of  the  pre- 


CYST.  179* 

paration,  he  recognized  neither  their  relation  to  the  alveoli  nor  their 
character  in  general.  He  regards  them  as  altered  and  hypertrophied 
muciparous  glands. 

Thus,  encysted  alveolar  cancer  is  accounted  for  and  explained  in  the 
same  manner  as  medullary  carcinoma. 

4.  Upon  the  internal  parietes  of  cysto-sarcomata  there  are  known  to 
occur  (in   the   so-called   cysto-sarcoma  proliferum)  warty,   foliaceous,  ' 
bulbous  vegetations,  as  also  pedunculate  cysts.     The  former  often  attain 
to  a  considerable  size,  so  as  to  fill  up  the  space  of  the  cyst,  presenting  a 
flesh-like  aspect.     [For  an  explanation  of  these  phenomena,  the  reader 
is  referred  to  an  appendix  to  the  separate  section  on  cysto-sarcoma.~] 

5.  In  goitre,  besides  others,  there  occur  cysts  filled  with  thyroid  gland 
parenchyma  of  accessory  growth.     We  have  often  the  opportunity  of 
witnessing  the  process  of  this  endogenous  production  in  its  incipient 
stage.     From  the  inner  parietes  of  the  cyst  arise  delicate,  transparent, 
protuberant,  vascularized  excrescences,  in  the  interior  of  which  a  new 
creation  of  gland-vesicles  takes  place. 

6.  Finally,  in  the  domain  of  physiology,  we  encounter,  upon  the  vas- 
cular plexuses  in  the  lateral  ventricles  of  the  brain,  a  formation  which, 
as  comparative  microscopical  investigations  teach  us,  fully  coincides  with 
the  excrescences  still  before  us.     Upon  the  lateral  plexuses  of  vessels 
are  seated  great  multitudes  of  delicate,  red,  vascularized  villi.     These 
consist,  beneath  an  epithelial  covering,  of  a  transparent,  multifariously 
projecting,  fretted,  hollow  growth,  in  the  protuberances  of  which  run 
arched  bloodvessels  of  no  inconsiderable  size.     Here  we  seldom  fail, 
especially  upon   subjects  advanced  in  years,  to  find  numerous  little 
cystlets,  for  the  most  part  lodged  in  those  protuberances.     Generally 
speaking  they  do  not  outgrow  a  certain  measure,  a  diameter  of  from 
2*5  th  of  a  millimetre  up  to  a  cyst  discernible  by  the  naked  eye,  and  dif- 
fering from  what  are  usually  called  cysts  of  the  vascular  plexus.     By 
dint  of  a  repeated  development  of  central  nuclei,  the  majority  are 
wrought  into  concentrically  laminated  growths,   and  undergo  incrus- 
tation. 

The  very  common  so-called  cysts  of  the  vascular  plexus  are  not  genuine 
cysts.  Numerous  examinations  have  convinced  us  of  their  being  dilata- 
tions of  the  hollow  growth  which  constitutes  the  villus  of  the  bloodvessel 
plexus.  This  dilatation  pre-eminently  affects  the  villi  adjacent  to  the 
tortuous  bloodvessels  upon  the  convexity  of  the  arch  described  by  the 
vascular  plexus.  Accordingly,  they  are  clusters  of  gibbous  and  in- 
dented vesicles,  separated  by  the  indentations  into  several  loculi.  Little 
remnants  of  villi  are  often  to  be  detected  upon  them.  We  have  fre- 
quently observed  the  dilatation  of  the  villus  at  its  commencement.  In 
this  manner,  the  so-called  cysts  of  the  vascular  plexus  answer  to  the 
pouches  into  which  the  excrescences  constituting  villous  cancer  widen. 
Besides  other  matters,  they  contain  areolar  tissue,  sometimes  to  perfect 
repletion,  so  that,  in  this  respect,  they  may  be  likened  to  the  excres- 
cences upon  the  internal  membrane  of  the  cysts,  and  especially  to  those 
which,  through  the  development  of  areolar  tissue,  have  become  internally 
parenchymatous  ;  as,  for  instance,  in  the  cyst  of  sarcoma. 

The  contents  of  what  are  called  cysts  of  the  vascular  plexus  answer,  in 


'180  CYST. 

all  essential  points,  to  the  contents  of  cysts  proper.  They  consist  in  a 
watery  albuminous  fluid,  which,  with  a  certain  amount  and  quality  of 
its  accompanying  organic  elements,  becomes  turbid,  thickish  whey- 
like,  and  in  great  measure  supplanted  by  the  development  of  areolar 
tissue. 

These  elements  are — 

(a.)  Minute,  5Jo  millimetre-sized,  elementary  granules,  free,  or  nu- 
merously held  together  by  a  viscid  interstitial  substance. 

(6.)  Larger,  up  to  nucleus-sized,  spheroid,  occasionally  somewhat 
oblong  vesicles,  which  speedily  increase  to  ^gth  of  a  millimetre.  There 
are,  besides,  ordinary,  granular,  spherical,  and  oblong  nuclei  and 
granules. 

(c.)  The  larger  vesicles  are  simple,  or  successively  enshrined.  Some 
exhibit  a  double  outline,  that  of  the  inner  vesicle  often  lying  so  close  to 
the  outer  one  as  to  be  easily  overlooked.  In  other  cases,  the  two  are 
widely  parted,  the  inner  one  being  slightly  wrinkled  or  curled.  In 
others,  again,  there  is,  between  the  two  contours,  at  some  one  spot,  a 
space  defined  by  a  single  outline,  which  sometimes  resembles  a  shallow 
section  of  a  sphere,  and  is  particularly  marked  where  the  compressed 
contents  of  the  external  cyst  are  granular,  and  therefore  contrast  with 
the  limpid  contents  of  the  inner  vesicle.  In  some  instances  the  inner 
vesicle  is  small,  and  either  central  to  the*outer  one,  or  resting  upon  its 
wall.  The  latter  kind  probably  engenders  the  form  just  adverted  to. 

Other  vesicles,  again,  consist  of  three  or  of  four,  the  inner,  secondary, 
and  tertiary  ones  being  by  turns  central  and  extra-centrical.  This 
species  of  complex  and  involved  sheathing  is  met  with  in  very  small 
(aggth  millimetre-sized)  vesicles.  In  some  of  the  simple  vesicles  is  found, 
— in  place  of  a  wall-inclined,  secondary,  spherical  vesicle, — an  oblong, 
wall-attached  nucleus. 

(d.)  With  these  are  associated  many-layered,  smooth,  or  slightly  gib- 
bous cysts,  between  the  lamellae  of  which  oblong  nuclei  are  often  found 
inserted.  The  central  vesicle  occasionally  holds  a  multitude  of  the  most 
various  primary  and  secondary  forms, — elementary  granules  (nucleoli) ; 
spherical,  oblong  nuclei ;  simple  and  compound  vesicles,  and  incrusta- 
tions of  vesicles.  These  laminated  growths,  for  the  most  part,  undergo 
an  incrustation  proceeding  from  the  central  layers. 

(e.)  We  also  find  the  cysts  of  the  vascular  plexus  to  contain  commonly 
in  the  shape  of  a  mucus-like  substance,  deposited,  as  it  were,  from  the 
fluid,  and  mostly  infiltrated  with  fine  sand-granules,  a  transparent 
blastema  pervaded  with  round  and  oblong  nuclei.  This  gradually  forms 
into  areolar  tissue,  displaces  the  moisture,  and  ultimately  fills  up  the 
entire  space  of  the  cyst,  in  the  meshes  of  which  the  aforesaid  forms  all 
lie  imbedded.  Within  the  structureless  blastema  we  perceive  the  oblong 
nuclei  bent  in  accommodating  curves  around,  and  closely  attached  to, 
the  vesicles  (alveolar  textural  arrangement).  Such  cysts  gradually 
shrivel  around  these  their  contents,  and  finally  become  extinct. 

The  aforesaid  cysts  are  very  delicate,  commonly  clear  and  transparent ; 
some  refract  the  light  with  a  whitish  tone,  their  contents  appearing 
somewhat  denser ;  in  others,  the  contents  are  of  a  reddish  shade ;  in 


CYST.  181 

others,  again,  finely  granular,  as  though  coagulated  ;  in  others,  lastly, 
the  contents  consist  of  a  multitude  of  sharply-defined  granules.  To  this 
class  belong,  more  especially — 

(/.)  Globular  bodies,  in  which  the  outline  of  a  cyst-wall  is  wanting, 
and  which  represent  lightly  granulated  spheres. 

(g.)  Lastly,  the  vascular  plexus  cysts  often  contain  a  whitish,  chalky 
fluid.  This  consists  almost  entirely  of  fat-globules,  and  gradually  thickens 
into  a  lardaceo-cretaceous  pap,  around  which  the  cyst  speedily  shrivels, 
and  perishes. 

The  vesicles  and  granulated  spheres,  the  incrustations,  the  areolar 
tissue  developments  and  the  fat-globules,  render  the  contents  of  the 
vascular  plexus-cyst  more  or  less  opaque. 

Y.  Finally,  we  have,  in  the  well-founded  expectation  of  throwing 
additional  light  upon  cyst-development,  examined  their  fluid  contents. 
For  this  purpose  we  have  found  the  contents  of  small  (young)  cysts, 
those,  for  example,  which  occur  upon  the  broad  ligaments  of  the  womb, 
or  within  the  cortical  substance  of  the  kidney,  especially  serviceable. 
They  include  a  multiplicity  of  elementary  forms,  essentially  identical 
with  what  are  observed  in  the  vascular  plexus  cyst.  Nor  is  their  occur- 
rence limited  to  the  cyst  itself. 

The  fluid,  semi-fluid  contents  of  the  sac,  consist  in  an  albumen-holding 
humor,  which  possibly  presents  various  phases,  the  chief  one  being,  how- 
ever, that  in  which  it  constitutes  colloid.  In  it  are  contained  those 
elementary  forms  which  are  here  fraught  with  peculiar  interest.  It  is 
here  adverted  to  irrespectively  of  what  was  before  stated  concerning  its 
parenchymatous  contents,  as  well  as  of  whatsoever  changes  hemorrhage 
or  exudation  may  give  rise  to  within  the  cyst. 

Besides  the  ddbris  of  an  epithelial  layer  generally  composed  of  granu- 
lated, nucleolated  nuclei,  there  are  found : 

(a.)  Similar  free  nuclei,  some  holding  two,  three,  or  four  nucleoli, 
some  visibly  exceeding  the  usual  size  of  nuclei.  Along  with  them  here 
and  there,  a  form  of  which  it  is  problematic  whether  it  be  a  nucleated 
cell,  or  a  full-grown  nucleus,  with  a  nucleolus. 

(6.)  Granules,  the  larger  of  which  being  ?J0th  of  a  millimetre  in 
diameter,  are  obviously  vesicles. 

(c.)  To  both  are  associated  vesicles  and  cysts,  which  grow  from  the 
size  of  the  aforesaid  granules  to  J$ih  millimetre,  and  as  will  be  seen, 
beyond  this. 

These  cysts  offer  many  points  of  interest : 

(a.)  They  are  simple,  or  else  compound,  incased  within  and  within. 
As  regards  the  latter,  we  meet  in  the  first  place  with  simple  vesicles, 
within  which  a  central  granule  or  nucleus-corpuscle  has  become  developed. 
This  progressively  enlarges  into  a  cyst,  in  which  the  same  process  may 
be  repeated.  In  a  cyst  are  often  contained  two,  three,  four,  and  more 
secondary  granules,  nuclei,  vesicles,  in  which  the  process  of  ingeneration 
is  still  further  repeated. 

(/?.)  Their  shape  is  commonly  spherical,  but  often  flattened  by  mutual 
compression.  Some,  owing  perhaps  to  the  inspissation  of  their  contents 
are  wrinkled,  bent  inwards,  more  or  less  regularly  indented.  This  applies 
to  the  simple  cyst  equally  with  the  compound,  affecting  in  the  case  of 


182  CYST. 

the  latter  all  the  involved  cysts  in  various  degrees,  or  it  may  be  only 
one,  and  that  the  innermost. 

Some  frequently  throw  out  various  projections,  prolonged  into  cylin- 
drical processes,  which  in  turn  display  ulterior  promontories,  or  it  may 
be  inlets.  This  applies  both  to  the  simple  cyst,  and  also  to  the  compound, 
affecting  all  the  layers  in  unison.  Occasionally,  the  projections  are 
obviously  determined  by  endogenous  development  out  of  multiplex  nuclei 
and  vesicles. 

7.  Their  contents  present  marked  differences  : 

The  contents  of  simple  and  compound  cysts  properly  consist  of  a 
viscid  fluid,  in  some  cases  translucent  and  colorless,  in  others,  of  a  reddish 
tint.  In  compound  cysts,  these  two  conditions  often  alternate  one  with 
the  other. 

Some  contain  in  and  along  with  the  said  fluid,  granules  in  various 
numbers,  even  to  thorough  repletion ;  some,  together  with  these,  clear, 
reddish-shaded  vesicles,  the  size  of  a  nucleus.  Others  contain  granu- 
lated, spherical,  oval  nuclei. 

The  fluid  contents  of  certain  cysts  appear  denser,  less  transparent, 
opalescent ;  of  others,  still  denser,  dully  transparent,  presenting  at  the 
same  time  a  marked  cloudiness.  In  others,  again,  the  density  is  still 
further  marked,  and  the  cloud  more  sharply  defined. 

This  cloud  results  from  a  parting  of  thfe  contents  into  spherical  cor- 
puscles, and  flaky  pellets  of  various  size.  In  a  given  cyst  it  seems 
tolerably  uniform,  or  else  it  consists  in  a  radius-like  fissuring  from  the 
periphery  towards  the  centre  of  the  cyst.  In  compound  cysts,  the  sepa- 
ration differs  in  degree  and  relative  amount  in  the  individual  cysts,  being 
often  more  developed,  either  in  the  outer  or  in  the  inner  cysts,  and  in  one 
or  other  not  present  at  all. 

The  fissuring  presents  much  that  merits  attention.  In  simple  vesicles 
or  cysts,  it  extends  from  the  periphery  towards  the  centre,  where  the 
radii  or  the  points  of  the  wedges  of  substance,  bordered  by  the  fissures, 
converge.  In  compound  cysts,  a  fissure  present  in  the  external  vesicle, 
borders  either  upon  the  contour  of  a  nucleolus,  of  a  nucleus,  or  of  the 
secondary  cyst,  in  which,  if  there  be  a  fissuring,  it  is  independently 
constituted.  Or  again,  the  fissure-lines  of  the  cysts  correspond  with 
one  another — in  other  words,  the  fissure  affecting  the  external  cyst  is 
prolonged  through  the  second,  third,  fourth  inner  cysts,  &c.,  with  a 
radius  common  to  all.  This  is  rendered  possible  by  the  metamorphoses 
of  the  cyst-wall  about  to  be  explained. 

With  the  condensation  of  its  contents,  the  wall  of  the  cyst  gradually 
disappears,  seemingly  blending  with  the  contents  to  a  uniform  mass. 
As  in  the  case  of  the  so-called  cysts  of  the  vascular  plexus,  the  entire 
cyst  is  transformed  into  a  dull,  opalescent,  resilient,  simple  or  com- 
pound, colloid  globule,  which  splits  under  the  covering  glass  plate, — a 
spherical,  oval,  cylindrical,  or  nodulated  colloid  mass.  To  this  cate- 
gory, doubtless  belong  the  unexplained  bodies  seen  by  Kohlrausch  in  a 
renal  cyst.  (Vogel,  Path.  Anat.) 

This  relation  of  the  cyst-wall  further  determines  the  contents,  reduced, 
after  the  completed  process  of  separation,  to  an  aggregate  of  stellate 
flocculi,  which  break  up  into  roundish,  opalescent  fragments  of  various 


CYST.  183 

size.     There  are  always  present  globular  debris  from  which  numerous 
fragments  of  this  kind  have  become  separated. 

This  relation  of  the  cyst-wall  occasions  the  breaking  up  of  the 
already  fissured  contents,  either  spontaneously,  or  from  pressure,  into 
stratiform,  or  wedge-like  fragments,  as  is  particularly  frequent  in  in- 
crusted  specimens.  The  same  cause  produces  the  linear  disruption, 
through  pressure  of  the  smooth  compound  colloid  sphere,  athwart  many 
of  its  strata.  These  formations,  together  with  the  remaining  amorphous 
colloid  contents  of  the  cyst,  are  sometimes  tinged  of  a  brownish  or  of 
a  yellow  hue,  from  imbibed  pigment. 

An  ulterior  change  in  these  formations,  which  should  here  be  noticed, 
is  their  incrustation  with  phosphate  and  carbonate  of  lime.  It  com- 
monly affects  the  compound  laminated  cysts,  but  not  unfrequently,  the 
simple  ones  also ;  the  comprehensive,  equally  with  the  small  ones ;  the 
smooth,  equally  with  the  gibbous.  It  invariably  emanates  in  the  simple 
cysts  from  the  centre,  in  the  compound,  from  the  central  layer,  whether 
this  consist  of  a  simple  nucleus,  or  a  group  of  nuclei  in  a  vesicular 
nucleus-development.  The  secondary  cysts  lying  side  by  side  within  a 
simple  or  a  compound  cyst,  become  incrusted  independently  of  each 
other,  and  also  of  the  parent  cyst.  The  cysts  affected  with  incrustation 
are  those  whose  contents  have  undergone  the  condensation  before 
referred  to. 

Lastly,  many  cysts  contain  granules  and  globules,  which  are  shown 
to  be  of  a  fatty  nature,  the  cyst  resembling  in  some  sort  a  colossal  gra- 
nule-cell. 

(d.)  There  is  in  the  primary  and  secondary  formations  within  the 
cysts  hitherto  spoken  of,  frequently  a  colorless  hyaline,  or  colored  col- 
loid substance,  in  the  shape  of  roundish,  oval,  facetted,  poppy-seed, 
millet-seed,  or  lentil-sized  pellets  and  flakes,  and  of  larger  misshapen 
masses.  It  is  uniform  in  character  with  the  opalescent,  self-separating 
contents  of  the  aforesaid  microscopic  cysts. 

The  presence  of  all  the  semi-transparent  and  opaque  formations 
renders  the  cyst-contents  whitish,  or  turbidly  yellow.  This  portion  of 
the  cyst's  contents  is  frequently  separated  in  the  form  of  a  deposit. 

With  this  I  conclude  the  catalogue  of  facts,  relating  to  the  cyst.  I 
shall  now  proceed  to  recapitulate  these  facts,  and  endeavor  to  elicit 
from  them  such  deductions  as  they  appear  to  warrant  and  uphold. 

1.  The  cyst  is,  with  respect  to  its  organization  and  secretory  function, 
an  independent   hollow   growth,    essentially  based  upon  a  substantive 
element. 

2.  At  the  characteristic  turning-point,  between  a  primary  (embryonic), 
and  a  secondary   phase,   overstepping  the  microscopic  scale,  the  cyst 
consists  of  a  structureless  vesicle  of  from  jV-th  to  y^th  of  a  millimetre 
in  diameter,  and  an  encircling  fibrous  layer,  maintaining  various  grades 
of  development.     To  these  is  added,  as  endogenous  production,  a  nucleus 
or  cell-formation,  limited  to  an  epithelial  stamp.     The  cyst  here  com- 
pletely resembles  the  glandular  vesicle  of  the  thyroid  gland,  and  of 
the  supra-renal  capsules.     The  encircling  fibrous  layer  furnishes  the 
alveolus  for  the  reception  of  the  structureless  cyst. 

3.  The  elementary  germ  of  the  structureless  vesicle,  resides  in  the 


184  CYST. 

nucleus, — nay,  inasmuch  as  the  nucleus  is  obviously  generated  out  of  an 
elementary  granule,  it  resides  in  the  elementary  granule  itself.  The 
latter  grows  by  intussusception  into  the  nucleus,  and  the  nucleus  at 
once  in  the  same  wise  into  the  structureless  vesicle.  The  nucleus 
arising  out  of  the  elementary  granule  either  retains  the  character  of  the 
latter,  as  a  smooth,  polished,  sharply-pencilled  vesicle,  or  acquires  the 
well-known  granulated  character.  It  is  obviously  the  former,  in  par- 
ticular, that  becomes  developed  into  the  structureless  cyst,  even  the 
granulated  nucleus,  however,  enters  upon  this  development,  its  contents 
clearing  up  during  the  process,  but  resuming  the  granulated  character 
afterwards. 

This  history  of  cyst-development  is  essentially  corroborated  by  the 
expansion  of  the  cell-nuclei,  of  so  frequent,  although  by  no  means 
exclusive,  occurrence  in  cancer-cells;  an  expansion  first  pointed  out 
with  precision  by  Virchow,  but  which,  owing  to  the  identity  of  develop- 
ment of  the  normal  gland  vesicle,  and  of  the  cyst,  cannot  be  regarded 
as  heteroplastic.  It  consists  in  the  development  of  the  cell-nucleus  into 
a  comprehensive  cyst,  identical  with  that  evolved  out  of  the  naked 
nucleus. 

This  corroboration  is  rendered  complete  by  the  fact,  that,  in  the 
inflated  cell-nucleus,  an  elementary  granule  present  as  a  nucleolus, 
expands  into  a  nucleus,  generates  within  itself  another  neucleolus,  and 
forthwith  becomes  a  second  cyst.  This  in  my  opinion  affords  important 
evidence  of  the  vesicular  nature  of  the  nucleus,  and  of  its  evolution  out 
of  the  elementary  granule,  through  simple  intussusception-growth  which 
Reinhardt  has  shown  to  be  a  property  of  the  chyle-,  the  lymph-,  and 
the  pus-corpuscles.  (See  Virchow's  ArcJiiv.,  vol.  1,  fas.  3.) 

4.  To  the  cyst  in  its  primitive   condition,  as  a  structureless    cyst, 
there  accedes  from  without,  and  blends  with  it,  a  more  or  less  marked 
fibrous  texture.     The  cyst  in  this  secondary  condition,  consists  of  a  wall 
of  a  definite  texture,  with  an  internal  lining  of  epithelium,  and  is  at 
once  endowed  with  an  enormous  capacity  of  growth. 

The  structureless  cyst  is  developed  in  a  consolidated,  structureless 
blastema,  commonly  studded  with  spherical  and  oblong  nuclei,  or  else 
in  a  nidus  of  caudate  and  other  cells.  In  the  former  case,  the  cyst  is 
speedily  surrounded  with  a  fibrous  formation  following  the  course  of  the 
encircling  oblong  nuclei,  the  cells  contiguous  to  the  cyst  assuming  an 
elongated,  ribbon-like,  caudate  shape,  and  arraying  themselves  in 
parallel  order  around  it.  A  remarkable  tendency  to  enter  upon  this 
relation  to  the  cyst  is  shown  by  the  caudate  cells,  which  constitute  so 
many  cancerous  tumors.  They  first  associate  themselves  one  by  one  to 
very  small,  young,  vesicles,  and  shortly  overlay  them  in  quite  dispro- 
portionate numbers.  Even  oblong  nuclei  will  fasten  upon  young  vesicles 
of  the  kind. 

5.  This  arrangement  of  the  elements  of  a  texture,  brought  about  by 
the  presence  of  young  cysts,  and  consisting  in  an  essential  portion  of 
those  elements  uniting  to  form  capsules,  and  alveoli  for  the  reception  of 
the  cysts,  I  have  termed  alveolar  textural  arrangement,  or  the  alveolar 
textural  type,  and  assigned  to  it  a  range  extending  far  beyond  the  limits 
of  a  special  heterologous  formation.     This  establishes  the  distinction 


X 
CYST.  185 

between  the  alveolar  textural  arrangement  and  many  similar,  but  diffe- 
rently engendered,  meshworks,  cavernous  structures,  and  the  like. 

6.  The  cyst,  in  its  primitive  state  as  a  structureless,  vesicle,  and  also 
in  its  development,  fully  corresponds  with  the  simple  gland  vesicle — for 
example,  the  thyroid  gland,  and  its  development,  as  seen  more  especially 
in  hypertrophy  of  the  thyroid  gland.     Nay,  the  same  anomalies  of 
development,  consisting  in  arrest  and  involution,  are  common  to  both. 
On  the  other  side,  the  insensible  progress  of  the  gland-vesicle,  when 
imbedded  in  its  fibrous  alveolus,  from  its  normal  standard  to  the  morbid 
condition  of  a  cyst,  constitutes  a  process  completely  one  with  the  secon- 
dary stage  of  cyst  development. 

7.  Cysts  form  singly,  or  else  collectively,  in  greater,  often  in  redun- 
dant number.     New  cysts  often  arise  within  the  fibrous  wall  of  a  parent 
cyst.     There  occurs  also  an  endogenous  multiplication  of  the  cysts,  new 
ones  being  developed  in  the  fluid  or  parenchymatous  contents  of  a  cyst. 
In  the  former  case,  they  do  not  in  their  development  overstep  the  pri- 
mitive condition,  for  lack  of  the  adventitious  element  requisite  to  con- 
solidate and  advance  the  structureless  vesicle  into  the  true  cyst. 

8.  The  cyst,  as  appears  under  the  circumstances  discussed  in  §  6, 
possesses,  under  the  same  form,  a  different  import.     This  it  reveals  more 
especially  in  the   character  of  the  textural  elements  frequently  engen- 
dered upon  its  internal  wall  through  the  medium  of  the  excrescences. 
These   repeat,  now  a   normal,    now   a   heterologous   parenchyma — for 
example,   that  of  carcinoma.      We  are  here  reminded  of   Hodgskin's 
idea,  which  has,  from  time  to  time,  been  much  too  inconsiderately  and 
hastily  condemned. 

9.  Cysts  are  for  the  most  part  abiding  growths,  which  often  attain  to 
a  monstrous  circumference.     There  are,  however,  cysts  which  never,  or 
very  rarely,  exceed  a  certain  volume,  about  that  of  a  grain  of  millet,  or 
of  a  pea,  at  which  point  they  burst,  void  their  glassy,  mucoid,  colloid 
contents,  perish,  and  are  substituted  by  fresh  ones.     Exploding  cysts, 
to  which  belong  the  cysts  constituting  the  so-called  vesicular  polypi,  the 
ovula  Nabothi.     The  cyst  in  its  primitive  state  as  a  structureless  vesicle 
appears  to  burst,  in  like  manner,  and  eject  the  brood  elements  it  con- 
tained.    At  all  events,  open  vesicles  now  and  then  occur  which  do  not 
appear  to  have  become  so  by  external  means. 

10.  On  the  inner  surface  of  the  cysts  are  found  simple,  bulbous  or 
dendritic  excrescences,  which  represent  a  bulb-shaped,  pouch-like,  or  a 
variously  projecting,  hollow-growth,  branching  out  into  secondary  and 
tertiary  pouches,  and  consisting  in  a  hyaline,   structureless  membrane, 
studded  with  spherical  and  oval  nuclei. 

These  bodies  shoot  from  the  inner  surface  of  the  larger  cysts,  isolated 
or  collected  in  groups,  sometimes  from  the  innermost,  sometimes,  naked, 
from  a  deeper  layer,  and  through  slight  fissures,  or  more  spacious  gaps, 
formed  by  the  cyst-wall  giving  way.  Or,  coming  from  the  deeper 
layer,  they  raise  the  internal  structureless  or  striated  lamina  of  the  cyst- 
wall  into  a  vesicle,  which  they  afterwards  perforate,  and  with  which 
they  coalesce,  becoming  blended  together  with  them  into  a  meshwork. 
In  the  smaller  cysts  they  raise  up  the  epithelium,  and  retain  it  as  an  in- 
vestment. 


186  CYST. 

They  contain  an  albuminous  fluid,  or  one  possessing  the  germs  both  of 
physiological  texture,  and  of  heterologous  parenchyma.  Through  its 
accumulation  they  become  changed  into  protuberant  or  pouch-like  sacs, 
which  last  are  often  patent  at  their  free  extremities.  There  is  often  de- 
veloped within  them  a  fibrous  texture  which  imparts  to  them  the  cha- 
racter of  considerable,  fleshy,  shallow-lobed  (condyloma-like)  tumors,  as 
in  the  cyst  of  cysto-sarcoma ;  or  they  shrivel  into  fibroid  growths  and 
perish.  Above  all  they  frequently  engender,  in  the  terminal  bulbs  of 
their  branches,  young  cysts,  thus  mediating  the  endogenous  production 
of  secondary  cysts. 

They  frequently  enter  upon  the  final  transformation  into  a  stroma  of 
fibrous  texture,  which  receives  into  a  mesh  work  or  into  alveoli  the  ele- 
ments of  parenchymata  of  various  kinds. 

They  occur  not  only  in  cysts,  but  also  upon  serous  and  synovial  mem- 
branes, upon  mucous  membranes,  growing,  in  all  cases,  into  the  respec- 
tive cavities.  Their  development  frequently  out  of  deep  fissures  in  the 
cyst-wall,  renders  it  likely  that  they  spring  at  some  depth  out  of  hetero- 
logous parenchymata,  and  ultimately  penetrate  into  larger  spaces  formed 
by  the  yielding  of  textures. 

They  appear  everywhere  as  germ-nidi,  and  as  carriers  of  certain  tex- 
tural  elements.  In  the  cyst  itself  their  tendency  is  to  fill  up  space  by 
determining  the  production  of  physiological  and  pathological  parenchy- 
mata, but  in  particular  the  endogenous  multiplication  of  the  cyst  itself. 
In  the  vascular  plexus,  and  in  the  so-called  Haversian  glands,  they 
occur  as  physiological  growths.  They  have  sometimes  the  characters  of 
a  benign,  sometimes  of  a  malignant  new  growth. 

The  correlation  between  the  chorion-villi  and  the  cyst-formation 
occurring  within  them  in  the  shape  of  acephalo-cystis  racemosa  of 
Laennec,  and  between  the  subject  under  discussion,  is  hardly  to  be 
doubted.  I  have,  however,  failed,  of  late,  to  obtain  fresh  materials  for 
investigating  this  point. 

The  cyst,  in  its  primitive  state,  is  subject  to  various  anomalies  produc- 
tive of  arrest  of  its  development, — of  involution  of  the  sac.  These 
anomalies  consist  essentially  in  changes  in  the  contents  of  the  young 
cyst ;  it  is  therefore  desirable,  in  the  first  place,  to  point  out  what  is 
most  remarkable  in  the  contents  of  the  cyst  generally. 

The  first  and  most  marked  phenomenon  in  point,  is  the  presence  of 
delicate,  diaphanous,  for  the  most  part  simple,  but  also  nucleated  vesi- 
cles, the  one  kind  including  reddish  glistening,  the  other  kind,  colorless 
limpid  contents.  In  growths  consisting  of  several  cysts,  encased  one 
within  the  other  (expanded  nuclei),  it  is  common  for  one  or  the  other  to 
include  reddish  contents,  whilst  the  remainder  exhibit  a  colorless,  clear, 
or  slightly  opalescent  fluid.  Occasionally  these  different  contents  alter- 
nate several  times.  These  vesicles  vary  from  the  size  of  a  nucleolus,  or 
a  nucleus,  to  that  of  a  vesicle  o^th  of  a  millimetre  in  diameter,  or  more. 
The  small  ones  occur  in  all  physiological  and  pathological  fluids  con- 
taining plasma  ; — in  the  blood,  in  the  humor  Morgagni,  in  exudates,  in 
the  juice  of  various  heterologous  growths,  in  the  grayish  blastema  sup- 
plying the  place  of  atrophied  nerve-medulla  in  the  brain  and  spinal 


CYST.  187 

tube.  The  larger  ones  occur  more  particularly  in  conjunction  with  cyst- 
growths,  and  as  forming  part  of  the  contents  of  cysts. 

The  parietes  of  the  vesicle,  whatever  may  be  the  nature  of  the  con- 
tents, are  uniform  with  the  sheath  of  the  nucleus.  They  resist  the 
influence  of  acetic  acid,  or  else  the  latter  occasions  thickening  of  the 
membrane,  and  a  sharper  contour  of  the  vesicle.  An  examination  of 
the  contents  is  essentially  facilitated  by  the  following  occurrence :  In 
the  above  summarily  mentioned  fluids,  there  probably  is  always,  freely 
suspended,  a  reddish  glistening  fluid  or  viscid  substance,  both  in  little 
globules,  and  in  larger  masses,  moulded  into  various  forms,  and,  where 
the  current  is  impeded,  divided  into  smaller  portions.  This  substance  is 
rapidly  dissolved  by  acetic  acid.  It  forms  the  contents  of  nuclei,  and 
also  of  cells, — very  commonly  of  cells  the  recipients  of  the  brood-nuclei 
of  the  thyroid  gland  vesicle,  the  brood-nuclei  of  young  cysts, — some- 
times the  contents  of  pus-cells,  and  of  young  cells  generally.  Here, 
again,  it  is,  together  with  the  very  delicate  cell-wall,  soluble  in  acetic 
acid.  In  like  form  we  often  observe,  especially  in  the  contents  of  cysts, 
a  colorless,  viscid  substance,  equally  soluble  in  acetic  acid,  and  probably 
identical  with  the  ordinary  colorless  cell-contents. 

These  two  substances  are,  to  all  appearance,  unimportant  modifica- 
tions of  the  same  material.  Colorless  elementary  granules  and  nuclei, 
after  evaporation  of  their  surrounding  watery  medium,  when  placed 
under  the  influence  of  liquor  potassse,  swell,  and  assume  a  reddish  tint ; 
we  might,  therefore,  fancy  that  a  difference  in  density  determined  the 
modification,  the  reddish  gleam  being  simply  due  to  a  diminution  of 
density. 

The  colorless  (denser)  contents  are  coagulated  by  the  addition  of 
acetic  acid,  becoming  still  denser,  bereft  of  transparency,  opalescent. 

Akin  to  this  change  is  that  of  conversion  into  a  colloid  substance. 

Occasionally  a  fatty  transition  is  suffered. 

Let  us  now  proceed  to  pass  in  review  those  phases  of  the  cyst,  as  a 
structureless  vesicle,  which  we  have  set  down  as  anomalies  of  its  develop- 
ment. 

(a.)  In  the  first  place,  numerous  cysts,  like  the  brood-nuclei  and  cells 
they  frequently  contain,  break  up,  in  their  primitive  state,  as  structure- 
less vesicles.  This  is  occasionally  preceded  by  a  dehiscence  and  empty- 
ing of  the  vesicle.  In  other  cases,  the  contents  of  the  cyst  are  first 
converted  into  fat,  a  transformation  of  the  cyst  to  a  growth  resembling 
the  granule-cell. 

(b.)  Cysts  developed  within  a  fluid  [the  fluid  contents  of  a  cyst],  for 
lack  of  attachments,  and  of  certain  textural  elements  accruing  to  the 
structureless  membrane  from  without,  do  not  overstep  the  primitive  con- 
dition. They  succumb  to  the  processes  of  involution  already  described, 
or  enter  upon  changes  hereafter  to  be  explained. 

(<?.)  A  remarkable  arrest  in  the  cyst's  growth  attaches  to  the  endoge- 
nous development  of  secondary  and  tertiary  vesicles,  resulting  in  those 
laminated  cyst-growths  destined  to  undergo  early  incrustation.  The 
lamination  may  be  restricted  to  a  system  of  many-sheathed  or  encased 
vesicles,  developed  out  of  either  central  or  extra-centrical,  parietal 
nuclei.  Or  else  several  distinct  laminated  systems  occur  within  a  com- 


188  CYST. 

mon  peripheral  one,  several  nuclei,  simultaneously  or  independently  de- 
veloped within  a  secondary  or  tertiary  vesicle,  having  expanded  into 
vesicles,  and  these,  again,  generated  their  own  proper  central  or  extra- 
centrical  nuclei.  This  explains  the  frequent  deviations  from  the  sphe- 
rical or  oval  forms.  The  size  of  these  growths  varies  greatly.  We  may 
have  nuclei  in  which  a  nucleus- corpuscle  is  inflated  to  a  vesicle  simply 
bordering  upon  the  contour  of  the  nucleus,  or,  again,  of  *th  of  a  milli- 
metre in  diameter. 

(d.)  Another  arrest  of  the  development  of  a  cyst,  fraught  with  its 
eventual  destruction,  consists  in  the  conversion  of  its  contents  into  colloid. 
The  cyst  becomes  reduced  to  a  sheathless  colloid  mass,  becomes  fissured 
or  furrowed,  and  so  broken  up  into  fragments.  In  laminated  vesicles, 
this  transformation  may  affect  all  the  vesicles  uniformly  or  unequally, 
often  a  single,  and  that  generally  the  central  one,  which,  in  this  case, 
generates  no  further  nucleus,  so  that  all  ulterior  lamination  ceases. 

The  consolidation  to  colloid  affects  the  contents,  not  alone  of  the  cyst, 
but  also  of  its  basis,  the  nucleus,  and  the  elementary  granule  of  nucleo- 
lus.  This  we  observe  alike  where  cysts  are  involved  in  the  said  conver- 
sion, and  also  under  circumstances  where  no  cyst-development  takes 
place  beyond  a  slight  extra-normal  inflation  of  the  nucleus.  Such 
transformed  elementary  granules  and  nuclei  occur  in  medullary  cancers. 

(e.)  Next  akin  to  colloid  conversion  is  the  incrustation  of  the  cyst, 
and  of  its  bases  (the  nucleus  and  elementary  granule)  with  phosphate 
and  carbonate  of  lime.  It  affects  both  simple  and  laminated  cysts.  These 
incrusted  growths  vary  from  the  bigness  of  a  nucleolus  and  a  nucleus, 
to  |th,  or  even  J  of  a  millimetre  in  diameter.  They  are,  however,  most 
commonly  of  about  ^th  to  J0th  of  a  millimetre.  They  are  identical  in 
form  with  the  simple  and  laminated  cysts,  namely,  spherical,  oval,  smooth 
or  nodulated,  lobulated,  spindle-shaped,  or  cylindrical,  occasionally 
hourglass-shaped,  trefoil-shaped,  facetted. 

On  compression,  they  frequently  split  up  into  regular  flaky  or  wedge- 
like  sphere  sections,  a  circumstance  connected,  no  doubt,  with  the  capa- 
bilities of  colloid  substances  to  split  asunder  according  to  determinate 
radial  systems.  At  other  times  they  break  up  into  smaller  roundish 
stellse,  or  into  wedge-shaped  fragments. 

In  laminated  cysts  the  incrustation  is  wront  to  commence  with  the 
innermost  layers,  where  the  colloid  consolidation  of  the  cyst's  contents 
begins.  From  hence  it  proceeds  to  the  external  layers.  Many  incrusta- 
tions are  seen  in  which  the  outer  layer  is  as  yet  free,  the  incrustation, 
as  seen  from  above,  appearing  to  surround  it  as  with  a  light  fringe.  In 
vesicles  with  several  collateral  filial  vesicles,  the  latter  become  in- 
crusted — beginning  in  like  manner  with  the  inner  layer — whilst  the 
parent  cyst  and  its  layers  remain  free  for  some  time  longer. 

It  occurs  originally  either  in  molecular  or  in  crystalline  form,  the 
completed  incrustations  displaying,  now  a  stellate,  now  a  crystalline, 
stratiform  aggregation. 

To  sum  up,  it  would  appear  that  it  is  not  the  cell  out  of  which  the  cyst 
becomes  developed,  but  the  nucleus,  and  that  this  latter  again  is  evolved, 
through  endogenous  growth,  out  of  the  nucleolus  or  elementary  granule. 


SARCOMA    AND    CARCINOMA.  189 

Lastly,  that  the  structureless  cyst-wall  is  not,  as  we  once  supposed,  an 
independent  textural  development. 

12.    SARCOMA  AND   CARCINOMA. 

Kindred  new  growths,  important  from  their  frequency  no  less  than 
from  the  question  arising,  in  every  concrete  case,  as  to  their  innocency 
or  malignancy.  They  constitute  an  extensive  group,  comprising  most 
of  the  so-called  heteroplases.  They  occur,  now  as  independent  tumors, 
which  usurp  the  place  of  normal  textures,  now  as  throwing  out  a  multi- 
plicity of  roots  or  branches  through  the  textures,  interlacing  with  their 
elements,  destroying  these,  and  assimilating  them  to  their  own  proper 
substance. 

Solidified,  and  more  especially  fluid  blastemata  enter  very  largely  into 
their  composition,  both  becoming  developed  after  their  own  manner  into 
the  elements  described  under  the  heading,  "Metamorphosis  of  Blastema." 
They  become  wrought  into  a  stroma,  various  in  extent  and  in  design, 
which  forms  the  receptacle  for  fluid  blastema  and  its  elements.  Along 
with  the  fibrous  stroma  developed  out  of  solidified  blastemata,  massive 
fibrous  textures,  evolved  out  of  cells  and  nuclei,  are  derived  also  from 
fluid  blastemata.  Lastly,  the  structureless  parietes  of  parent-cells,  here 
so  numerous,  enter  into  an  immediate  fibrillation. 

The  ulterior  development  of  the  parent-cell  determines  that  very 
common  texture,  the  alveolar,  as  also  the  resemblance  with  certain 
gland-textures  ;  for  example,  the  salivary  glands,  the  thyroid  gland,  the 
cortical  substance  of  the  kidneys,  &c.,  resemblances  which  formerly  and 
even  recently  gave  rise  to  such  designations  as  "  sarcoma  pancreaticum," 
&c.  When  these  heterologous  formations  affect  osseous  structures, 
they  often  determine  the  extensive  new  growth  of  a  texture  simulating 
bone. 

Their  chemical  composition  involves,  besides  the  gluten  of  the  fibrous 
elements,  several  other  gluten-like  (pyin-like)  substances,  along  with 
albumen,  casein,  and  fats. 

In  size  they  vary  from  that  of  a  just  cognizable  new  growth  to  that 
of  a  human  head,  and  upwards. 

In  form  they  occur  as  spherical,  roundish,  knotty,  lobulated,  stellate, 
irregular,  ramified  tumors.  The  form  of  infiltration  belongs  more  espe- 
cially to  cancers. 

Of  consistency  we  meet  with  every  gradation,  from  the  fluid  and 
gelatinous,  to  the  consolidated,  fibro-cartilaginous. 

Bloodvessels  enter  into  the  fabric  of  all  these  new  growths,  although 
to  a  very  different  amount ;  some  being,  relatively  to  their  volume, 
sparingly  vascularized,  whilst  others  are  distinguished  by  their  redun- 
dant vascularity.  In  those  of  the  latter  kind,  the  collapse  of  the  blood- 
vessels after  death  occasions  a  marked  change  in  color,  consistence,  and 
volume. 

These  tumors  have  a  pathology  of  their  own,  being  especially  subject 
to  hypersemia,  hemorrhage,  and  inflammation  with  its  sequelae,  more 
especially  ulceration  and  necrosis. 

Many  undergo  a  process  of  involution  and  extinction,  either  sponta- 
neous, or  evoked  by  preliminary  disease,  especially  by  inflammation. 


190  SARCOMATA. 

They  originate  at  all  periods  of  extra-uterine  life,  and  are  occasionally 
found  of  considerable  size  in  the  new-born  infant. 

Upon  the  whole,  no  texture  or  organ  is  exempt  from  them.  There  is, 
however,  something  peculiar  and  remarkable  in  the  affinity  evinced  by 
certain  types  for  particular  organs. 

We  would  distinguish  these  new  growths,  as  shadowed  forth  in  the 
heading,  into  two  series,  the  one  comprising  innocent,  the  other  malig- 
nant formations,  for  the  grounds  of  which  distinction  we  must  refer  the 
reader  to  the  section  on  "  Organized  New  Growths." 

We  have  selected  the  term  sarcoma  to  designate  the  benign  growths, 
not  because  of  any  especial  analogy  with  muscle-flesh,  but  in  order  to  fix 
and  define  a  name  familiarized  by  long  usage,  and  also  by  no  little  abuse. 
The  malignant  we  shall  lea've  in  possession  of  their  ancient  characteristic 
appellation  cancer, — carcinoma. 

To  catalogue  the  species  of  these  new  growths  in  a  strictly  philo- 
sophical order,  is  not  feasible  at  this  day.  We  shall  best  respond  to  the 
requirements  of  practice  by  determining  the  species  upon  the  grounds  of 
predominant  structural  and  chemical  relations,  a  due  regard  being  had 
to  the  general  habitudes  of  a  growth.  The  varieties,  numerous  in  the 
instance  of  certain  species,  are  for  the  most  part  concerned  with  elemen- 
tary texture,  by  which  the  general  habitudes  are  not  essentially  in- 
fluenced. 

SARCOMATA. 

These,  as  already  stated,  represent  benign  new  growths.  They  are 
always  purely  local  affections,  and  therefore  exist  almost  always  as  a 
solitary  growth.  They  are  most  commonly  due  to  mechanical  influences ; 
accordingly  their  seat  is  generally  in  organs  or  parts  near  the  surface, 
and  obnoxious  to  such  influences.  They  are  curable  by  complete  extir- 
pation ;  that  is  they  do  not  recur  at  the  same  spot,  and  still  less  do  they 
multiply  in  other  localities. 

They  generally  constitute  circumscribed,  spherical,  stellate,  and  clavate, 
superficially  lobulated  tumors.  Often  enough  they  ramify  throughout 
the  texture,  nestling  and  luxuriating  through  the  elementary  parts,  so 
that  these  perish,  degenerating,  so  to  say,  into  the  heterologous  growth. 

They  often  increase  to  a  very  considerable  volume,  and  this  within  a 
brief  period. 

They  aifect  the  areolar  tissue,  the  fibrous  membranes, — especially  the 
submucous, — the  muscles,  inter-muscular  tissue,  and  submucous  muscu- 
lar textures  (uterus),  the  bones  (osteo-sarcoma),  particularly  the  facial 
bones,  glandular  organs,  the  mammary,  the  parotid  glands,  even  the 
testicle ;  and,  in  rare  instances,  the  brain. 

The  osteo-sarcoma  is  often  inclosed  within  a  skeleton  sheath  formed 
by  the  distended  bone,  which  eventually  becomes  perforated.  In  rare 
instances  a  new  growth  of  bone  enters,  in  the  shape  of  an  inner  skeleton 
or  framework,  into  its  composition. 

Generally  speaking,  sarcomata  are  more  frequent  than  carcinomata  in 
the  early  periods  of  life — those  of  childhood  and  of  boyhood. 

They  seldom  lapse  into  a  process  of  ichorous  ulceration  spontaneously, 


SARCOMATA.  191 

although  frequently  through  inflammation  brought  on  by  the  membra- 
nous expansions  which  covered  them,  namely,  the  general  integument  or 
the  mucous  membrane,  inflaming  and  sloughing  away,  so  as  to  leave 
them  denuded.  This  ichorous  ulceration  may  even  lead  to  cachexia  and 
exhaustion ;  the  inflammation  itself,  however,  never  gives  rise  to  a 
specific  infection,  and  to  a  multiplied  production  of  the  heterologous 
growth. 

Sarcomata  lend  themselves  naturally  to  a  division  into  three  species. 

1.  G-elatinous  Sarcoma. — A  very  frequent  heterologous  formation, 
of  which  there  are  several  varieties.  It  consists,  besides  some  albumen, 
almost  wholly  of  a  gluten-,  chondrin-,  or  pyin-like  substance. 

The  varieties  are  principally  referable  to  consistence,  which  varies 
from  that  of  gelatin  to  that  of  fibro-cartilage,  conforming  itself  partly 
to  the  amount  of  water  held  by  the  glutinous  basement,  partly  to  that  of 
the  textural,  and  especially  the  fibrous  elements  developed  within  it. 

(a.)  The  first  variety  is  a  very  soft,  jelly-like,  nearly  limpid,  tremu- 
lous, yellowish-gray  new  growth,  sparingly  vascularized.  It  is  the  gela- 
tinous tumor — the  collonema  of  Johannus  Muller. 

J.  Muller  describes  the  parenchyma  of  collonema  as  made  up  of 
spherules,  some  of  which  are  much  larger  than  blood-globules,  inter- 
spersed with  crystalline  needles. 

We  have  met  with  the  gelatinous  sarcoma  in  different  organs ;  more 
commonly,  however,  in  the  brain,  and  in  the  mammary  gland,  bearing, 
if  not  all  the  attributes  of  Muller 's  collonema,  at  least  so  close  a  re- 
semblance to  its  texture  as  to  remove  all  doubt  as  to  their  identity. 
Our  specimens  presented,  on  the  one  side,  a  perfectly  embryonic  form 
of  collonema,  on  the  other  side  one  more  highly  developed,  and  border- 
ing upon  the  following  varieties  : 

A  roundish,  goose-egg-sized,  gelatinous  tumor,  from  the  mammary 
gland,  consists  of  a  very  soft,  amorphous  blastema,  interspersed  with, 
for  the  most  part,  very  minute  elementary  granules,  and  delicate  little 
twig-like  fibre  rudiments.  This  blastema  is  permeated  by  whitish  mem- 
branous septa,  differing  from  the  basement  in  nothing  save  in  their 
greater  consistency. 

A  very  bulky,  lobulated,  gelatinous  tumor  from  the  brain,  displays 
branched  fibres,  resembling  the  elastic,  with  very  numerously  imbedded 
nucleated  cells,  mostly  larger  than  the  pus-cell. 

One  extirpated  along  with  a  portion  of  the  inferior  maxilla,  exhibited 
a  stroma,  consisting  of  elastic,  branched  fibres,  shooting  forth  twig-like, 
out  of  a  stem. 

Lastly,  a  fourth,  from  a  spermatic  cord,  showed  single  spiral,  elastic- 
like,  but  transparent  fibres,  in  an  otherwise  amorphous,  tenacious  blas- 
tema. 

(6.)  The  second  variety  comprises  a  series  of  kindred  new  growths, 
marked  by  a  progressively  increasing  density  and  resistance,  and  mostly 
by  a  very  pronounced  stellate  and  lobulated  structure.  A  white,  areolar 
tissue-like  fibrillation,  cognizable  with  the  naked  eye,  and  bearing  in  its 
interstices  nuclei  and  cells,  caudate  nuclei  and  cells,  and  nucleus-fibres, 
enters  largely  into  its  composition. 

There  is  here  often  both  a  microscopical  and  also  a  ruder  alveolar 


192  SARCOMATA. 

texture  and  cyst-formation,  which  lend  to  the  heterologous  growths  the 
semblance  of  a  glandular  structure ;  the  alveoli  and  cysts  being  the 
especial  holders  of  the  gelatinous  moisture. 

This  variety  of  sarcoma  is  generally  endowed  with  considerable  vas- 
cularity.  During  life,  the  new  growth  exhibits  various  shades  of  red- 
ness, and  offers  to  the  feel  either  a  woolly  resiliency  or  a  greater  degree 
of  elastic  firmness.  In  the  after-death  collapse,  it  is  of  a  grayish-red  or 
reddish-white,  flabby,  and  in  various  degrees  resistant. 

(c.)  The  third  variety  consists  of  a  firmish,  amorphous  basement, 
broken  up  into  solid  fibres,  after  the  manner  of  the  intercellular  sub- 
stance of  hyaline  cartilage,  and  teeming  with  cells  more  or  less  re- 
sembling those  of  cartilage.  This  variety  approximates  in  its  elementary 
structure  to  the  cartilaginous  new  growths,  to  the  enchondroma,  with 
which  the  gelatinous  sarcoma  is  manifestly  and  essentially  cognate. 

These  varieties,  more  especially  the  last  two,  are  often  found  com- 
bined in  one  and  the  same  new  growth. 

The  gelatinous  sarcoma,  besides  the  rarer  localities  specified  in  the 
instance  of  collonema,  namely,  the  brain  and  the  mammary  gland,  affects 
the  parotis,  the  subcutaneous  areolar  tissue,  the  intermuscular  parts,  and 
with  great  frequency  the  periosteum  and  the  bones,  more  especially  of 
the  face.  The  second  variety  is  particularly  marked  by  the  immense 
circumference  to  which  the  growth  becomes  developed,  often  within  a 
brief  space  of  time,  through  redundant  lobulation  and  ramification. 

2.  The  albumino-fibrous  tumor ;  fibrous  sarcoma. — This  tumor  is  of 
a  fibrous  texture,  and  is  distinguished  from  other  and  especially  the  pure, 
gluten-yielding  fibroids,  by  its  albuminous  contingent. 

The  genesis  of  the  fibres  and  their  relation  to  the  fluid  albuminous 
blastema  vary. 

(a.)  The  fibre-texture  becomes  developed  out  of  the  fluid,  that  is  the 
albuminous,  blastema,  according  to  the  laws  of  the  cell-theory. 

(b.)  The  fibrous  texture  originates  out  of  consolidated  blastema,  form- 
ing in  this  case  a  stroma,  in  whose  interstices  the  fluid  blastema  is  con- 
tained and  becomes  developed. 

The  fibre  varies  in  all  the  forms  derived  from  solid  and  fluid  blastema. 
In  particular,  all  the  forms  described  under  "  Metamorphosis  of  Blas- 
tema," recur  here  as  the  stroma.  Again,  we  have  recognized  in  one  of 
the  forms  specified  in  the  section  on  "  Gluten-yielding  Fibroids,"  the 
transition  from  the  latter  to  fibrous  sarcoma. 

Varieties  of  this  sarcoma,  dependent  upon  the  form  and  arrangement 
of  the  fibres,  might,  accordingly,  be  numerously  adduced.  A  frequent 
appearance  in  the  albumino-fibrous  sarcoma,  is  the  formation  of  the 
cystic  and  alveolar  texture. 

Just  as,  in  the  gelatinous  sarcoma  it  is  the  gluten-like  blastema, — so 
it  is  a  predominantly  albuminous  blastema  with  which  the  fibrous  paren- 
chyma becomes  drenched,  or,  with  which  the  gaps  of  the  fibrous  stroma, 
the  cystic  and  alveolar  spaces,  become  occupied. 

The  albumino-fibrous  tumor,  like  the  gelatinous  sarcoma,  occurs  in 
areolar  tissue,  in  the  periosteum,  especially  the  submucous  periosteum ; 
and  in  submucous  and  muscular  strata  of  areolar  tissue,  as  fibrous,  pha- 
ryngeal,  nasal,  uterine  polypi,  &c.  Moreover,  it  affects  bones,  especially 


CYSTO-SARCOMA.  103 

those  of  the  face,  and,  more  rarely,  glandular  organs,  the  parotis,  the 
mammary  gland,  the  testicle.  It  is  spherical,  elliptic,  single,  or  more 
often  tabulated  and  ramified,  more  or  less  resilient,  vascularized,  turges- 
cent  new  growth,  with  a  texture  fibrous  to  the  naked  eye. 

3.  The  albumen-like  fibrous  tumor.  (Johannes  Miiller.) — The  albu- 
men-like sarcoma  is  a  gibbous,  tenacious,  albumen-like  tumor,  sparely 
and  but  partially  vascularized  where  its  texture  is  slightly  reddened  and 
less  firm.  It  consists,  generally,  of  a  white  or  yellowish-white,  solid, 
fragile  mass.  Here  and  there  it  exhibits  clefts  or  fissures,  which  con- 
tain a  synovia-like  fluid.  It  consists,  in  part,  of  a  uniform,  almost 
structureless  or  indistinctly  fibrous  mass.  According  to  Muller,  it  is 
made  up  of  a  basement  of  multifariously  interwoven,  microscopic  fibres, 
amongst  which  are  interspersed  a  vast  multitude  of  globules.  The  tumor 
is  said  to  have  yielded  no  gluten  by  boiling ;  the  scanty  extracts  to  have 
been  thrown  down  by  the  reagents  of  casein,  and  the  insoluble  main 
mass  to  have  represented  an  albuminous  body. 

We  have  only  once  encountered  this  new  growth,  namely,  in  the  bone, 
within  a  loopholed,  bony  sheath. 

A  very  interesting  variety  of  sarcoma  is  the 

CYSTO-SARCOMA. 

The  combination  of  the  heterologous  parenchyma  with  cyst-formation, 
the  groundwork  of  which  is  here,  as  elsewhere,  the  parent  cyst  and  the 
alveolus,  together  imparting  to  the  new  texture  the  glandular  aspect. 

Just  as  the  basis  of  the  cyst  in  sarcoma  is  identical  with  that  of  the 
pure  cyst,  so,  in  like  manner,  do  the  types  of  both  simple  and  compound 
cyst-formation  here  recur.  In  point  of  fact,  therefore,  the  forms  de- 
signated by  Muller  as  varieties  of  cysto-sarcoma,  offer  a  mere  repetition 
of  those  types. 

These,  varieties  are  : 

1.  Cysto-sarcoma  simplex. — The  cysts  imbedded  in  the  parenchyma 
of  the  sarcoma,  are  on  their  inner  surface  smooth,  or  simply  speckled 
with  little,  isolated,  injected  elevations  of  parenchymatous  texture. 

2.  Cysto-sarcoma  proliferum. — In  the  same  parenchyma  are  found 
numerous  intra-cystic  cysts,  some  flattened  along,  others  attached  by  a 
pedicle  to,  the  parietes  of  the  parent-cyst.     With  A.  Cooper,  we  have 
seen  some  of  these  secondary  cysts  as  hollow  appendices,  or  even  free 
within  the  parent  cyst.     In  like  manner  parenchymatous  masses  of  a 
fibrous,  or  of  an  acino-glandular  structure,  grow  as  pedunculate  offshoots 
into  the  cavity  of  the  parent  cyst.     This  offers  a  transition-link  to  the 
following  variety. 

3.  Cysto-sarcoma  phyllodes. — A  large  clavate  tumor,  consisting  of  a 
firm  mass,  and  presenting  a  fibrous  torn  surface.     Within  is  one  large 
cavity,  or  there  are  several  cavities,  unprovided  with  any  cognizable 
proper  membrane,  into  which  firm,  sarcomatous,  red,  vascularized,  folia- 
ceous,  or  warty,  tufted,  broad-based,  or  pedunculate,  bulb-shaped,  some- 
times cauliflower-like,  or  fringed  and  villous  excrescences,  germinate  and 
grow.     These  consist  of  the  same  substance  as  in  the  former  case,  but 
are  mostly  less  dense  and  more  succulent,  readily  drawn  out  length-wise 

VOL.  I.  13 


194  CYSTO- SARCOMA. 

into  fibres,  or  spread  out  to  a  membrane,  showing  that  they  exist  in  a 
folded  and  rolled-up  condition.  Along  with  them  the  cavity  contains  a 
viscid  humor. 

In  this  description  of  the  cysts  in  sarcoma,  we  easily  recognize  the 
types  of  pure  cyst-formation.  Whatever  interest,  however,  attaches  to 
this  repetition,  its  description  is  inconclusive  as  regards  the  real  nature 
of  the  new  growths.  The  main  feature  is  still  the  heterologous  paren- 
chyma, which  becomes  the  cysto-sarcoma  without  dofiing  its  primitive 
character.  This  parenchyma  is  that  of  the  gelatinous  and  albuminous 
sarcoma.  A  peculiarity,  in  point  of  form,  consists  in  the  membranous 
basement  of  sarcoma  phyllodes,  in  its  above-described  exquisite  form. 
Cysto-sarcomata,  and  the  species  phyllodes  most  particularly,  often  at- 
tain to  a  very  considerable  magnitude.  They  are  frequent  in  the 
genital  organs,  of  females  more  especially,  in  the  mammary  gland,  in 
the  ovary,  less  often  in  the  testicles.  In  a  word,  they  occur  in  all  those 
organs  specified  as  liable  to  the  development  of  sarcoma,  in  its  several 
species. 

APPENDIX. 

[Since  the  publication  of  Rokitansky's  treatise  on  cyst  and  on  goitre, 
he  has  devoted  much  attention  to  the  subject  of  cysto-sarcoma,  the 
chronic  mammary  tumor  of  the  late  Sir  A?  Cooper,  the  imperfect  hyper- 
trophy of  the  mammary  gland  of  Mr.  John  Birkett,  the  mammary 
glandular  tumor  of  Mr.  Paget.  Rokitansky,  in  an  essay,  read  before 
the  Imperial  Academy  of  Sciences,  at  Vienna,  in  Jan.  1853,  on  "  The 
new  growths  of  the  mammary  gland  texture,  and  its  relation  to  cysto- 
sarcoma,"  gives  the  details  of  several  minute  examinations  of  these 
tumors,  the  results  of  which  are  thus  summed  up  :  "In  the  one  case  are 
found  imbedded  within  a  small  transparent,  succulent  tumor,  acinus-like 
formations,  consisting  of  a  structureless  membrane,  and  replete  with 
nuclei.  In  the  second  case  are  found,  in  the  texture  of  nodules,  of 
which  the  tumor  is  composed,  numerous  delicate  fissures  bordered  by  a 
fringe,  in  which  the  matrix  substance  is,  with  the  naked  eye,  seen  to 
shoot  inwards,  in  the  form  of  almond-  or  bulb-like  projections.  There 
are  also  larger  cavities  present,  into  which  stellate  masses  project.  A 
magnifying  power  shows  that  these  projections  themselves  begin  to  be- 
come lobulated  at  their  terminal  points.  In  other  cases  an  extreme, 
lobulated,  textural  mass  is  thrown  forward  into  a  fibrous  cyst ;  some  of 
its  lobes  being  again  enveloped  by  a  cyst.  Upon  the  surface  of  others 
are  found  furrows,  whose  margins  spring  up  into  conical  and  bulbous 
excrescences,  and,  together  with  these,  larger,  open,  cyst-like  chinks. 
In  the  texture  of  those  lobules  are,  moreover,  channels  and  acinus  for- 
mations, as  also  upon  the  cut  surface,  chinklets  cognizable  with  the 
naked  eye,  which,  under  a  magnifying  power  of  90  diameters,  appear  as 
considerable  cavities  branching  out  in  all  directions,  whilst  between  their 
emissaries  the  neighboring  texture  shoots  inwardly  in  the  shape  of 
conical  and  bulbous  excrescences." 

It  results  from  this  that — 

1.  The  acinus-like  cavity  with  its  emissaries  resides  in  a  layer  con- 
sisting partly  of  embryonic,  partly  of  fibro-cellular  tissue. 


APPENDIX.  195 

2.  The  cavity  enlarging,  coalesces  with  the  matrix  substance,  which 
grows  into  its  space  in  the  shape  of  conical  and  bulbous  excrescences, 
whilst  these,  at  their  free  extremity,  throw  out  lesser  projections. 

3.  As  these  multiply,  the  number  of  the  fissure-like  emissaries  in- 
creases. 

4.  They  shoot  out  from  all  points  around  the  dilating  hollow  growth, 
or  from  individual  points,  or  from  one  point  only,  into  the  excavation. 
Where  they  are  wanting,  the  dilatation  of  the  cavity  is  uniformly  that 
of  a  cyst  with  smooth  parietes. 

5.  This  dilatation  is  often  very  considerable,  and  the  excrescences 
may  also  attain  to  a  vast  size. 

6.  In  these  excrescences,  a  secondary  formation  of  acinus-like  growths 
takes  place,  in  which  the  events  which  occurred  in  the  primary  one  are 
severally  repeated.      This   occasions    certain    excrescences  to    appear 
encysted  whilst  others  remain  bare. 

7.  At  the  surface  of  the  excrescences  are  observed  furrows  or  open 
cyst-like  clefts,  into  which  excrescences  intrude  in  like  manner. 

Dissenting  from  the  view  to  which  Mr.  Paget  inclines,  namely,  that 
these  tumors  originate  as  cysts,  subsequently  lose  their  cyst  form,  and 
continue  to  grow  as  solid  masses,  differing,  moreover,  with  Mr.  J. 
Birkett,  who  attributes  them  to  a  blastema  effused  into  the  areolar  tissue 
of  the  mammary  gland,  Rokitansky  contends  that  an  acinus-like  hollow 
growth  which  determines  this  tumor,  and  repeats  one  element  of  the 
mammary  gland,  becomes  developed  within  a  matrix  of  new-formed  con- 
nective tissue,  which  primarily  constitutes  the  tumor.  And  this  tumor 
is  by  no  means  encysted,  unless  an  adventitious  fascia-like  sheath  of 
areolar  tissue  be  called  a  cyst.  A  true  cyst  is  only  subsequently  de- 
veloped within  it  through  the  dilatation  of  the  said  gland-structure,  the 
connective  tissue  layer  being  expended  upon  the  construction  of  the 
fibrous  cyst-wall.  This,  growing  into  the  space  of  the  cyst,  and  carrying 
before  it  the  primitive  structureless  cyst-membrane,  works  out  an 
encysted  textural  mass,  an  encysted  tumor,  in  which  the  gland  elements 
are  reproduced. 

The  dendritic  excrescences,  therefore,  which  vegetate  in  the  cyst  of 
cysto-carcoma,  are  not,  in  Rokitansky's  opinion,  and,  as  he  once  held, 
outgrowths  from  the  internal  cyst-membrane,  but  intrusions  into  the  cyst 
of  its  own  cradle  mass,  or  matrix,  still  invested  with  the  primitive  cyst- 
membrane  and  its  epithelium. 

Cysto-sarcoma  simplex^  in  which  the  cradle  mass  does  not  intrude  at 
all  into  the  cavity  of  the  cyst,  is  of  the  rarest  occurrence. 

C.  proliferum  is  engendered  by  the  development,  within  the  terminal 
excrescence-bulbs,  of  the  acinus-like  cavities  into  filial  cysts,  and  the  in- 
growing of  the  cradle  mass  is  here  repeated. 

The  cysto-sarcoma  phyllodes  of  Johannes  Muller,  with  its  amply  de- 
veloped, warty,  cauliflower-  and  foliated-  or  cock's-comb-like  ingrowths, 
has  nothing  to  mark  it  beyond  the  size  and  development  of  the  excre- 
scences. The  cyst-membrane  is  here  no  longer  demonstrable,  having 
coalesced  with  the  cradle  mass  of  the  cyst. 

It  has  been  stated  that  the  dendritic  intrusions  into  the  cyst  may 
occur  at  one  point  only  of  the  cyst,  at  several  points,  or,  lastly,  at  all 


196  CANCER  —  CARCINOMA. 

points  simultaneously.  In  the  last  case  they  converge,  coalesce,  and 
eventually  fill  the  entire  cyst,  determining  thus  its  aggregate,  lobulated 
structure. 

With  two  exceptions,  the  one  mentioned  by  Johannes  Muller,  the 
other  by  Mr.  Paget,  of  these  tumors  occurring  in  the  breast  of  the  male, 
Rokitansky  knows  them  only  as  affecting  the  female  breast,  where  they 
are  generally  seated  at  the  inner  and  upper  part  of  the  mammary  gland. 

Their  figure  approximates  to  the  spherical.  Small  tumors  are  com- 
monly even  and  smooth,  greater  ones  irregularly  nodulated,  knobbed, 
lobulated,  at  the  same  time  tolerably  resistant,  elastic,  often  generally 
or  partially  presenting  the  feel  of  a  cyst  tense  with  fluid. 

The  skin  often  presents  a  livid  aspect,  and  is  traversed  by  dilated 
veins.  It  is  sometimes  found  coherent  with  the  tumor,  but  not  degene- 
rated. The  mammary  gland  becomes  displaced  by  large  tumors,  and 
wastes  away. 

These  tumors  have  an  enormous  capacity  of  enlargement,  growing, 
now  slowly,  now  rapidly,  often  with  lengthened  periods  of  arrest.  Oc- 
casionally they  disappear  spontaneously.  In  a  few  instances  several 
small  tumors  are  concurrently  present. 

They  are  usually  painless  ;  there  are  cases,  however,  in  which  the  pain 
is  excessive.  These  represent  Cooper's  irritable  tumor  of  the  breast,  a 
fibrous  tumor  (a  neuroma)  for  the  most  part  associated  with  the  present 
new  growth. 

The  individuals  affected  are  often  unwedded,  or  childless  females. 
The  married  and  child-bearing  are  however  not  exempt. 

The  tumors  are  innocent,  and.  although  often  recurrent  at  the  same 
spot  after  extirpation  (Mr.  Birkett  relates  a  case  of  their  reproduction 
five  times  in  succession),  not  so  beyond  the  range  of  the  mammary 
gland.  In  many  respects  they  are  analogous  to  the  fibrous  tumor  of 
the  uterus,  and  to  enchondroma. 

In  rare  instances  they  undergo  ulceration,  which  involves  the  super- 
imposed cutaneous  textures.] 

0.   CANCER — CARCINOMA. 

Heterologous  growths  not  distinguishable  from  sarcomata  by  definite 
generic  marks,  and,  like  these,  to  be  dealt  with  only  as  species,  but  con- 
trasting with  sarcomata  in  the  single  feature,  common  to  them  all,  of 
malignancy.  Carcinomata  originate  and  subsist  not  rarely  as  local  evils. 
Far  more  commonly,  however,  they  are  associated  with  a  dyscrasis, 
which,  in  point  of  fact,  often  precedes  and  engenders  the  cancer.  Hence 
the  multiple  appearance  of  carcinoma  as  the  sequel  to  a  single  one,  as 
the  sequel  to  the  extirpation  of  a  voluminous  and  hitherto  solitary  one. 
Hence,  in  other  cases,  the  original  appearance  of  cancer  in  several 
organs  simultaneously,  or  in  rapid  succession. 

Conformably  herewith,  carcinomata  can  rarely  with  adequate  reason 
be  attributed  to  external  local  causes,  whilst  it  is  very  common  for  them 
to  luxuriate  in  internal  organs  beyond  the  reach  of  palpable  influence 
from  without. 

The  crasis  which  gives  rise  to  the  production  of  cancer,  consists  mainly 


CANCER  —  CARCINOMA.  197 

in  a  preponderance  of  albumen,  a  clefibrination  (hypinosis),  for  the  par- 
ticulars of  which  we  must  refer  to  the  doctrine  of  crasis.  Concurrently 
with  this  we  have,  more  especially  in  the  medullary  crasis,  an  excess  of 
fat  in  the  circulating  fluid,  which  determines  a  complication  of  cancer 
to  be  discussed  in  a  more  appropriate  place ;  and,  again,  that  remarkable 
relation  of  exclusiveness  towards  ordinary,  fibrinous  tubercle. 

This  crasis  is  essentially  the  same  for  all  cancers,  only  exquisitely  de- 
veloped in  the  medullary  form.  This  may  be  inferred,  at  least,  from  the 
frequent  concurrence  of  various  cancer  species,  in  primitive  or  consecu- 
tive combination,  either  in  the  same  locality,  or  in  different  organs.  It 
may  also  be  inferred  from  the  circumstance  that,  after  extirpation,  the 
one  is  replaced  by  the  other  under  the  same  contingencies,  and  that, 
conforming  with  an  augmentation  of  the  crasis,  the  medullary  cancer  is 
generally  the  consecutive  one,  more  especially  where  the  substitution 
takes  place  rapidly. 

The  highest  grades  of  cancer-crasis  originate  through  infection,  that 
is,  through  the  reception  into  the  lymphatics,  or  more  especially  into 
the  bloodvessels,  of  cancer-cells,  or  of  cancer-blastema,  of  a  lax,  soft, 
semi-fluid  character.  The  blastema  is  carried  thither  by  imbibition, 
partly  in  the  mere  act  of  nutrition,  partly,  with  or  without  the  cancer- 
cells,  through  the  lymphatics  or  veins  laid  open  by  ulceration  of  the 
tumor,  or  lastly,  by  the  cancer  penetrating  into  the  canals  of  bloodves- 
sels. Infection  thus  brought  about,  occasions  locally,  or  it  may  be 
remotely,  both  in  large  bloodvessels  and  in  the  capillaries,  coagulations 
of  blood.  In  the  former  case,  these  are  cylindrical,  branched,  plug-like, 
or  clavate  coagula,  adhering  to  the  internal  bloodvessel  membrane,  or  to 
the  endocardium  (vegetations).  They  reveal  their  cancerous  nature  by 
their  external  medullary  characters,  as  well  as  by  their  vigorous  growth. 
In  the  capillaries  the  coagulation  assumes  the  form  of  the  cancerous 
depot — so  called  metastasis  (capillary  phlebitis). 

Cancer-formation  assumes  both  a  chronic  and  an  acute  course,  the 
former  being  the  more  ordinary  mode  of  occurrence  for  primitive  cancer ; 
whilst  secondary  cancer  production  is  brought  about  with  more  and  more 
rapidity  in  proportion  as  the  cancers  multiply.  Ulceration  and  extirpa- 
tion of  carcinoma  are  especially  apt  to  determine  its  very  acute  secondary 
formation.  Still  there  are  instances  of  highly  acute,  primitive,  general 
cancer  production.  Moreover,  the  individual  species  of  cancer  manifest 
marked  differences  in  this  respect,  both  the  first  development  and  the 
ulterior  growth,  for  example,  of  fibrous  cancer,  being  slow,  whilst  in  the 
case  of  medullary  cancer  they  are  incomparably  more  rapid. 

In  primitive  cancers,  the  blastema  is,  in  the  great  majority,  insensibly 
produced.  In  acute  cancer-formation  it  is  thrown  out  under  the  symp- 
toms of  hypersemia,  and  occasionally  of  inflammation.  In  the  latter 
case,  it  often  covers  serous  membranes  with  a  stratiform  cancer  exudate, 
or  infiltrates  and  hepatizes  the  lungs  with  cancerous  tubercles.  From 
what  has  been  said,  our  opinion  may  be  inferred  respecting  the  seat 
of  cancer,  in  opposition  to  that  of  Carswell  and  Cruveilheir,  who  refer 
its  origin  to  the  capillary  system.  But,  although  in  the  ordinary  pro- 
cess of  cancer-formation  we  look  upon  the  blastema  as  an  exudate  in  its 
broadest  sense,  we  by  no  means  question  the  origin  of  cancer  from 


198  CANCEB. 

coagulation  within  the  bloodvessels  after  the  type  of  depot-formation  in 
general  (see  Metastasis).  It  is  indeed  to  this  mode  of  development  that 
we  would  ascribe  the  rapid  cancer-formation  engendered,  in  brutes,  by 
the  injection  of  cancer-blastema. 

We  are  further  disposed — although  from  isolated  facts  only — to 
believe  in  cancer-formation,  through  a  conversion  of  certain  physiological 
elements  into  those  of  cancer.  In  the  liver,  namely,  we  occasionally 
light  upon  a  process,  limited  to  circumscribed  patches,  of  pallescence  and 
alteration  of  the  parenchyma,  with  some  augmentation  of  its  volume. 
Upon  further  examination,  the  portion  of  liver  so  affected  is  found  to 
consist  indubitably  of  hepatic  cells,  more  or  less  bereft  of  their  biliary 
and  coloring  matter,  and  of  an  intermediate,  whitish,  albuminous  blas^ 
tema, — as  though  the  hepatic  cell  had  become  transformed  into  the  cell 
of  medullary  carcinoma. 

Cancers  present  sometimes  well-defined,  easily  removable,  spherical, 
irregularly  knobbed,  lobulated,  branched  tumors,  which  may  lose  their 
circumscribed  character,  only  during  their  progress,  by  insinuating 
themselves  betwixt  the  elements  of  textures  hitherto  merely  displaced. 
Or  they  may  appear,  from  the  first,  as  infiltrated  heterologous  masses, 
involving  the  textures  without  definite  limits.  When  an  established  can- 
cerous mass  stretches  forth  from  one  organ  to  seize  upon  a  second,  the 
latter  is  forcibly  drawn  in  the  direction  of  the  first.  Membranous  forma- 
tions, in  particular,  become  attached  to  it  with  umbilical  flattening,  waste 
away,  and  become  perforated  by  the  heterologous  mass.  This  is  espe- 
cially the  case  with  fibre-carcinoma. 

The  size  of  carcinomata  greatly  varies.  As  tumors,  some,  and  in 
particular  the  gelatinous  and  medullary  forms,  attain  to  a  very  considera- 
ble magnitude.  A  special  notice  is  due  to  the  occurrence  of  cancer  in 
the  shape  of  little  millet-  or  hemp-seed-sized  tubercle-like  granules,  as 
detected  upon  serous  membranes.  They  have  the  import  of  medullary 
or  of  gelatinous  cancer, — sometimes,  however,  of  the  alveoli,  or  follicles 
of  alveolar  cancer.  In  membranous  formations,  the  magnitude  is  often 
represented  in  the  superficial  extension  of  the,  mischief  wrought  by  the 
infiltrated  malignant  matter, — as  in  cutaneous  cancer,  in  cancerous  de- 
generation of  the  dura  mater,  &c.  The  number  of  cancers  present  in  an 
individual  differs  materially,  varying  from  the  solitary  tumor  to  almost 
general  cancer-production. 

With  reference  to  the  occurrence  of  cancer  in  the  different  organs,  it 
may  be  generally  stated,  that  no  organ  or  texture, — not  even  cartilage 
— is  exempt  from  it,  with  the  solitary  exception  of  horny  textures. 
Certain  organs,  however,  are  hardly  ever  primarily  affected  with  cancer, 
being  attacked  only,  either  under  the  conditions  of  general  cancer-pro- 
duction, or  through  contiguity  with,  and  by  propagation  from  some  other 
organ  previously  a  prey  to  the  affection.  Thus,  primitive  cancer  of  the 
salivary  glands,  or  of  the  small  intestine,  very  seldom  occurs,  of  the 
lungs  or  of  the  spleen  scarcely  ever. 

As  regards  the  preference  of  cancer  for  different  organs,  the  following 
average  scale  of  frequency  might  be  established.  First,  the  uterus,  the 
female  breast,  the  stomach,  the  large  intestine,  and  especially  the  rectum ; 
next  comes  the  cancer  of  lymphatic  glands,  especially  as  retro-peritoneal 


CANCER.  109 

cancer-accumulation  in  front  of  the  vertebral  column;  hepatic,  peritoneal 
cancer ;  bone-cancer ;  cancer  of  the  skin,  and  of  the  lips ;  of  the  brain ;  of 
the  globe  of  the  eye  ;  of  the  testis  ;  of  the  ovary ;  of  the  kidneys ;  of  the 
tongue ;  of  the  oesophagus ;  of  the  salivary  glands  and  parotis.  Again  we 
meet  occasionally  with  cancers  in  large  serous  sacs,  as  in  the  peritoneum,  for 
instance,  adherent  only  by  very  inconsiderable  portions  of  areolar  tissue, 
or  vegetating  at  large,  and  sometimes  attaining  to  an  enormous  volume. 
Bone-cancer  has  now  and  then  a  sheath-like  skeleton ;  far  more  frequently, 
however,  it  scatters  the  bony  substance  piecemeal,  advancing  at  the  same 
time,  with  redundant  bone-formation,  in  the  shape  of  a  laminated, 
stellate,  thorny  stroma. 

Both  in  the  primitive,  and  still  more  in  the  secondary  appearance  of 
cancers,  we  may, — apart  from  all  disease  from  contiguity — discern 
certain  relations  of  sympathy ;  for  example,  between  uterus-  and  ovarium- 
cancer,  between  testicle-  and  kidney-cancer,  between  stomach-  and  liver- 
cancer,  between  stomach-  and  intestine-cancer ; — cancer  of  the  spleen  is 
probably  always  associated  with  liver-cancer. 

Generally  speaking,  cancer  is  more  common  in  the  middle  and  ad- 
vanced periods  of  life.  This  relates,  however,  only  to  the  cancer  of 
certain  organs,  more  especially  of  the  mammary  glands,  of  the  uterus, 
of  the  stomach  and  intestines.  All  other  cancers,  especially  those  of 
the  lymphatic  glands,  of  the  brain,  of  the  eyeball,  of  bone,  &c.,  occur 
e~ren  in  early  youth.  Of  the  individual  forms,  the  medullary  is  that 
most  common  at  the  earlier  periods  of  life.  In  rare  instances  it  is  met 
with  even  in  the  foetus. 

Cancers  are  themselves  subject  to  not  a  few  diseases,  amongst  others, 
to  hypersemia  with  intumescence,  and  to  hemorrhage.  The  most  im- 
portant amongst  them  is,  however,  inflammation.  Besides  this,  they 
are  liable  to  metamorphoses,  inductive  of  an  involution  of  th%  cancer ; 
and  these  are  developed,  apart  from  external  causes,  in  due  proportion 
to  the  vascularity  of  the  organ,  and  to  the  looseness  of  its  texture. 

Inflammation  may  become  kindled  spontaneously  in  the  interior,  the 
depths,  of  the  heterologous  growth.  Or  it  may  be  the  obvious  conse- 
quence of  external  influences, — of  irritating  medication  ;  of  exposure  of 
the  tumor,  after  perforation  of  the  investing  external  skin  or  mucous 
membrane,  to  contact  with  the  external  air  or  with  passing  secretions 
and  excretions. 

Its  distinctive  signs  are  identical  with  those  which  reveal  the  inflam- 
mation of  normal  structures,  and  they  are  developed  in  the  direct  ratio 
of  the  vascularity  and  looseness  of  texture  of  the  heterologous  growth. 
The  disease  has  a  marked  tendency  to  open  up,  and,  by  hemorrhage 
and  its  results,  to  destroy  such  texture.  It  takes  either  an  acute  or  a 
chronic  course. 

Its  products  are  sometimes  organizable ;  more  frequently,  however, 
and  more  voluminously,  they  are  coagulable,  yellow,  fibrinous,  or  yel- 
lowish-white albuminous,  deliquescent,  pus-like,  purulent,  and  ichorous, 
— very  often  hemorrhagic — exudates. 

Its  terminations,  besides  discussion  of  the  inflammatory  stasis,  and 
resolution,  are : 


CANCER. 

1.  Abiding  of  the  products  in  their  primitive  crude  condition,  or  else 
disruption,  wasting,  textural  conversion. 

We  have  here,  first,  to  advert  to  the  textural  conversion  of  consoli- 
dated fibrinous  exudates,  to  gluten-yielding  fibroid  textures  which  may 
spring  up  as  a  reinforcement  of  similar  stromata  already  in  existence. 
Secondly,  we  have  to  mention  the  development  of  embryonic  cancer 
elements  out  of  a  fluid  exudate,  as  represented  in  inflammatory  hyper- 
trophy,— increase  of  volume  of  the  new  growth.  Both  may  concur  with 
deliquescent,  pus-like,  ichorous  exudates,  and,  emphatically,  with  genuine 
pus-exudate. 

2.  Suppuration,  ichorous  production, — the  most  ordinary  termina- 
tion.    It  runs  either  an  acute  or  a  chronic  course,  with  or  without  simul- 
taneous granulations,  possessing  the  character  of  a  rapidly  developed 
new   growth — representing  certain  lax,   bleeding,    easily   suppurating, 
sloughing,  fungus-like  vegetations  upon  the  cancerous  ulcer.     This  pro- 
cess takes  place  either  in  the  depths  of  the  growth,  in  a  shut  space,  as 
so-termed  occult  cancer  ;  or  upon  the  free  surface  of  the  body  or  of  a 
mucous  cavity,  as  so-called  apert  or  open  cancer.     This  last  is,  for  the 
most  part,  marked  by  a  funnel-  or  crater-like,  deeply-extending  base, 
with  an  elevated,  mammillated  brink. 

Ichorous  destruction  of  a  cancer  is  very  commonly  followed  by  fugi- 
tive reproduction  of  the  fungus  upon  the  base  of  the  ulcer,  by  the  accu- 
mulation of  cancerous  matter  in  its  vicinity,  by  cancerous  degeneration 
of  the  implicated  lymphatic  glands,  and,  lastly,  by  the  translation  of 
cancer  to  other  organs. 

Even  independently  of  suppuration,  and  without  its  concurrence,  the 
necrosis  of  cancerous  growths,  both  small  and  great,  is  not  unfrequent. 

Ulcerating  and  necrosing  cancer — cancer-ichor — besides  its  corroding 
property^  is  marked  by  a  very  disgusting,  penetrating  fetor.  This  is, 
no  doubt,  essentially  due  to  the  sulphur  and  phosphorus  of  the  broken- 
up  protein  and  fatty  constituents  of  the  tumor,  especially  when  exposed 
to  the  air. 

We  have  here  still  to  advert  to  one  other  important  phenomenon.  In 
cancers  of  the  most  different  structure — in  all  cancers — we  meet,  not 
rarely,  with  a  yellow  substance,  sometimes  scattered  in  points,  some- 
times permeating  the  texture  as  straightened  or  serpentine,  ramified 
striae,  interlaced  to  form  a  mesh-  or  network,  or,  on  the  other  hand,  im- 
bedded in  considerable  masses.  It  is  a  yellow,  brittle,  consistent, — or 
a  soft,  friable,  unctuous,  glutinous  substance,  which,  if  closely  examined, 
is  found  to  consist  either  of  an  amorphous  blastema,  dotted  here  and 
there  with  minute  molecules,  and  interspersed  with  misshapen  nuclei 
and  with  more  or  fewer  of  the  elementary  cells  of  cancer, — or  else 
chiefly  scattered  or  grouped  elementary  granules  (or  fat-molecules),  of 
the  elementary  cells  of  cancer  replete  with  the  same  elementary  granules, 
and  lastly  of  fat-drops. 

This  substance  constitutes,  in  the  aforesaid  mesh-  or  network,  the  so- 
called  reticulum  of  Johannes  Miiller,  who,  regarding  it  as  essentially 
prolific  of  cancer-cells,  founded  upon  its  presence  a  new  species,  under 
the  denomination  of  cancer  reticulatum. 

On  this  point  we  cannot  quite  agree  with  Johannes  Miiller,  the  said 


CANCER.  201 

reticulum  not  being  confined  to  a  single  species  of  cancer,  but  occa- 
sionally met  with  in  every  form  of  the  disease. 

We  hold  it  to  be,  generally  speaking,  a  solidified  product  of  inflam- 
mation destined,  earlier  or  later,  to  break  up,  its  protein-substances 
along  with  the  contained  cancer-cells  undergoing  fatty  conversion.  We 
look  upon  this  process  as  both  interesting  and  important,  inasmuch  as, 
from  its  original  foyer  in  the  said  substance,  it  gradually  evokes  a  simi- 
lar process  throughout  the  cancerous  growth.  This  is  particularly  the 
case  where  the  substance  possesses  the  reticular  form,  so  as  to  master 
the  cancerous  parenchyma  at  all  points.  It  is  certain,  however,  that  the 
cancer-blastema  itself  undergoes  the  very  same  transformation,  and  that 
spontaneously. 

Cancers  for  the  most  part  prove  fatal,  sooner  or  later,  by  their  ex- 
hausting effects.  The  anaemia,  emaciation,  and  eventual  exhaustion  are 
the  result  of  the  luxurious  growth  of  a  single  tumor,  or  of  the  develop- 
ment of  a  multitude  of  smaller  tumors,  or  of  hemorrhage  or  ulceration. 
Moreover,  cancer,  like  other  heterologous  growths,  kills  through  mecha- 
nical hindrance  to  the  function  of  vital  organs  which  it  may  have  made 
its  abode — for  example,  the  brain.  Acute,  violent  cancer-production 
rapidly  destroys  life,  through  the  prefatory  and  attendant  hypersemia  of 
important  organs.  Suppurating  cancers  become  deadly  through  infec- 
tion of  the  blood,  and  pyaemia. 

However  seldom  the  extirpation  of  cancer  proves  successful,  its  spon- 
taneous cure  is  a  still  greater  rarity.  So  favorable  a  result  can  only  be 
brought  about  either  by  the  progressive  destruction,  necrosis,  and  partial 
rejection  of  the  tumor,  or  else  by  its  more  rapid  death  and  expulsion  ;  a 
circumscribing  suppuration  isolating  it  from  the  healthy  textures — (mam- 
mary, uterine  cancer). 

Other  processes  of  cure  present,  however,  greater  interest,  bearing 
the  character  of  an  involution,  a  decadency  of  the  cancer.  Such  are  : 

1.  Saponification  of  cancer,  a  metamorphosis  usually  evoked  by  the 
conversion  before  alluded  to  of  the  substance  constituting  the  reticulum. 
It  partly  consists  in  the  liberation  of  fats,  or  in  the  conversion  of  protein 
substances  into  fat,  with  consecutive  emulsive  and  saponaceous  blending. 
This  process,  the  above  designation  of  which  is  warranted  by  a  series  of 
minute  examinations,  attaches  chiefly  to  the  encephaloid,  medullary  car- 
cinoma, so  remarkable  for  its  proportion  of  fats  and  of  mutable  crude 
albumen,  and  occurs  more  especially  in  the  liver  and  the  womb. 

2.  Decadency,  wasting  of  the  tumor,  with  condensation,  solidification 
of  its  blastema,  liberation  of  salts  of  lime  in  the  shape  of  free  molecule, 
and  cell-incrustation.     It  affects  in  particular  the  denser  cancers  pro- 
vided with  a  solid  blastema  (intercellular  substance), — the  firmer  medul- 
lary and  the  fibrous  cancers.     The  ossification  and  cretefaction  of  in- 
flammatory products  in  cancer  often  gives  the  first  impulse  to   this. 
Here  again  ossification  and  cretefaction  (of  the  reticulum)  are  combined 
with  fatty  conversion. 

Although  carcinomata  are,  generally  speaking,  pre-eminently  malig- 
nant new  growths,  still  the  degree  of  their  malignancy  is  not  the  same 
in  all,  medullary  carcinoma  occupying  the  extreme  point  of  malignancy, 


202  COLLOID,  GELATINOUS  CANCER. 

whilst  colloid  and  the  epithelial  cancers  are  in  this  respect  the  mildest 
of  all. 

1.    COLLOID,    GELATINOUS   CANCER. 
Alveolar  Cancer  (0.  Areolaire}. 

In  the  array  of  cancers  we  again  encounter  a  gelatinous,  colloid  new 
growth,  namely,  gelatinous  cancer,  better  known  under  the  epithet 
alveolar,  derived  from  its  very  frequent  alveolar  fabric.  This  texture 
cannot,  it  is  true,  alone  mark  the  character  of  a  species.  It  occurs, 
however,  in  gelatinous  cancer  so  commonly,  and  at  the  same  time  in  so 
exquisite  a  form,  that  under  alveolar  cancer  nothing  else  is  understood 
than  gelatinous  cancer. 

This  species  occurs  under  two  forms  : 

1.  It  presents  a  yellowish-gray,  yellowish-red,  here  and  there  color- 
less, firm,  jelly-like,  transparent,  tremulous,  sizy,  and  when  voluminous, 
irregularly  clavate,  lobulated  mass.    This  consists  of  embryonic  elements 
— for  the  most  part  a  cell  analogous  in  appearance  to  the  pus-cell — in 
an  amorphous  colloid  blastema,  and  of  a  very  scanty,  very  delicate, 
fibrous  texture,  mostly  investing  the  interlobular  clefts.     Bloodvessels 
enter  into  its  composition  only  in  very  subordinate  number. 

2.  So-called  alveolar  cancer — cited  by  Otho,  in  1816,  as  a  peculiar 
kind  of  stomach-scirrhus — cancer  glelatiniforrne,  ar^olaire  of  Cruveil- 
hier. 

The  growth  consists  mainly  and  characteristically  of  follicles  (alveoli) 
of  either  very  delicate,  pellucid,  or  of  more  compact  and  massive,  white, 
satin-like,  shining  fibre-texture,  containing  a  colorless  or  a  pale  yellow, 
grayish,  diaphanous  gelatine.  Sometimes  the*  growth  consists  entirely 
of  these  follicles,  with  inconsiderable  columns  of  fibres  intervening  between 
them.  Then,  again,  in  the  deeper  layers,  towards  the  base  of  the  new 
growth,  we  shall  find  the  follicles  separated  by  a  copious,  firm,  white 
fibrous  stroma  of  new  parenchyma.  Its  quantity  stands  obviously  in  an 
inverse  ratio  to  the  quantity  and  the  grade  of  development  of  the  follicles. 
This  is  shown  most  especially  from  the  examination  of  cancers  of  the 
stomach  and  intestines.  The  walls  are  here  found  considerably  thickened, 
hard,  clavate,  the  inner  layer  presenting  a  multitude  of  collateral  and 
superimposed  hemp-seed-  or  pea-sized  follicles,  the  innermost  of  which 
open,  collapse,  and  cast  their  gelatine  upon  the  inner  surface  of  the 
stomach  or  intestine.  In  proportion  to  their  depth,  the  follicles  are, 
with  exceptional  patches,  smaller,  whilst  the  densely  fibroid  stroma  before 
referred  to  gains  the  ascendency.  This  character  of  alveolar  cancer  is 
frequent  both  in  the  stomach  and  intestines,  and  may  be  designated  as  a 
combination  of  the  alveolar  with  the  fibrous  form. 

A  closer  investigation  of  alveolar  cancer  presents  a  fibrous  texture  of 
the  parietes  of  the  alveoli,  and  of  the  inter-alveolar  substance.  Along 
with  areolar  tissue-like  fibrils,  black-contoured  granule-  and  nucleus- 
fibres,  with  similar  fibre  elements  arising  out  of  solidified  blastema  and 
uninfluenced  by  acetic  acid,  play  here  a  great  part.  In  the  gelatine  are 
found,  besides  elementary  granules  and  nuclei,  non-nucleated  and  nucle- 


COLLOID,     GELATINOUS    CANCER.  203 

ated  cells,  cells  with  one  or  with  multiple  cells,  parent  cells.  Besides 
these,  there  are  present  spindle-shaped,  caudate  cells, — under  certain 
conditions  granule-cells,  together  with  a  large  proportion  of  fat-molecule. 
Johannes  Muller  obtained  out  of  this  gelatine,  by  boiling,  no  trace  of 
gluten.  An  alcoholic  extract,  boiled  with  water,  contained  but  an  incon- 
siderable quantity  of  a  substance  somewhat  akin  to  ptyalin. 

According  to  Mulder,  the  main  constituent  of  alveolar  cancer  does 
not  occur  at  all  in  the  healthy  body.  We  regard  it  as  the  same  gluten- 
like  substance  which  furnishes  colloid  (see  Colloid),  and  which,  as  we  see, 
constitutes  numerous  new  growths,  both  benign  and  malignant. 

Cruveilhier  further  distinguishes  a  "cancer  ardolaire  pultace'e,"  the 
follicles  of  which  instead  of  transparent  gelatine,  contain  opaque  pulta- 
ceous  matter,  in  which  Boutin  Limousineau  has  detected  casein.  We 
hold  this  cancer  to  represent  a  transition  state  of  cancerous  gelatine  to 
fat,  with  its  ulterior  saponaceous  and  emulsive  combinations,  partly  in 
the  act  of  granule-cell  formation.  The  same  transformation  is  witnessed 
in  like  manner  in  the  first  form  of  gelatinous  cancer,  and  often  affecting 
considerable  portions  of  it.  It  is  in  its  nature  analogous  with  the  so-called 
reticulum  of  nbro-cancerous  textures. 

Alveolar  cancer  displays,  in  a  consummate  form,  all  the  characters 
assigned,  under  the  head  of  "  Cyst,"  to  the  alveolar  texture.  In  its  most 
pronounced,  that  is,  its  most  fully  developed  state,  it  offers  the  following 
varieties : 

(a.)  The  gelatine  accumulates  in  the  follicles  in  so  excessive  a  degree 
that  the  walls  of  the  alveoli,  owing  to  the  distension,  become  thinner  and 
thinner  until  reduced  to  a  mere  residue.  The  heterologous  mass  dege- 
nerates into  an  almost  uniform  tremulous  jelly,  traversed  by  delicate 
membranous  septa, — the  residua  of  the  alveolar  walls.  It  is,  in  point 
of  fact,  scarcely  to  be  distinguished  from  the  first  form  of  gelatinous 
cancer. 

(b.)  The  follicles  dilate  with  increase  of  substance  of  their  walls 
(hypertrophy)  into  cysts,  attaining  thus  to  an  enormous  magnitude.  This 
excessive  development  affects  the  follicles  more  and  more,  in  proportion 
as  they  are  more  peripheral.  The  new  growth  presents  an  aggregate  of 
collateral  and  superimposed  cysts,  one  or  more  of  which,  at  the  peri- 
phery, are  of  immense  circumference.  This  growth  resembles  the  com- 
pound cystoid,  inasmuch  as  a  redundant  alveolar  type  is  common  to  both, 
a  circumstance  readily  ascertained  in  the  instance  of  alveolar  gelatinous 
cancer  from  the  more  and  more  dense  fibro-alveolar  structure  exhibited 
on  its  cut  surface,  in  proportion  as  its  base  is  neared. 

The  contents  of  the  enormously  developed  follicles  include  all  the 
variations  observed  in  cystoids,  just  as  their  parietes  are  subject  to  the 
same  class  of  diseases. 

The  parts  most  liable  to  alveolar  cancer  are  the  stomach  and  the  large 
intestine,  the  serous  membranes  and  the  peritoneum  in  particular,  the 
omentum  (less  often  independently  than  in  association  with  cancer  of  the 
stomach  and  colon),  the  ovary,  the  bones,  in  rare  instances  the  kidney, 
the  uterus,  and  the  liver. 

Wherever  situate,  gelatinous  cancer  generally  enlarges,  and  that  often 
in  a  short  time,  to  enormous  masses.  Upon  serous  membranes,  espe- 


204  FIBRO-CARCINOMA. 

cially  the  peritoneum,  it  occurs  in  scattered  gelatinous  accumulations,  in 
little  millet-  or  pea-sized  tubercula,  or  in  larger  masses, — ^occasionally 
as  a  continuous  bulky  growth,  which  vegetates  from  a  few  points  of 
adhesion  only,  if  not  almost  free  within  the  peritoneum. 

Upon  the  peritoneum  the  first  form  is  predominant,  but  not  to  the 
exclusion  of  the  alveolar,  the  scattered  tubercula  having  the  character  of 
isolated  alveoli.  In  the  ovary  the  cyst-like  alveolar  cancer  is  prevalent, 
very  often  as  encysted  dropsy  of  the  areolar  cancer-form.  This  form 
occurs  also  now  and  then  in  the  bones. 

Gelatinous  cancer,  and  especially  the  alveolar,  is  sometimes  associated 
with  other  cancers.  This  combination,  however,  with  alveolar  cancer, 
must  be  considered  apart  from  the  alveolar  type.  This  type  constitutes 
every  cancer  an  alveolar,  but  not  a  combination  with  alveolar  gelatinous 
cancer.  Every  alveolar  cancer  may  be  regarded  as  associated  with 
fibrous  cancer,  by  virtue  of  a  notable  fibrous  inter-alveolar  substance.  A 
combination  with  medullary  cancer  is  generally  brought  about  by  the 
medullary  cancer  supervening  upon  the  alveolar,  the  peripherous  follicles 
of  which  fill  with,  and  are  eventually  overlapped  by  the  looser  encepha- 
loid  mass ;  or  else,  the  medullary  cancer  grows  into  the  cavities  of  the 
alveoli.  More  rarely,  the  gelatinous  cancer  supervenes  upon  the  medul- 
lary, in  the  cystic  and  alveolar  form. 

Pure  gelatinous  cancer  is  the  least  malignant  of  any,  and,  unless  it 
prove  exhausting  by  dint  of  surpassing  volume,  a  dependent  cachexia  is 
less  pronounced  than  in  other  cancers.  It  is  very  rarely  the  seat  of  in- 
flammation and  ulceration.  It  is  for  the  most  part  solitary,  although 
somewhat  prone  to  extend  to  contiguous  organs,  and  to  scatter  itself  over 
serous  surfaces,  in  the  manner  already  adverted  to. 

2.    FIBRO-CARCINOMA. 

Simple  Carcinoma. 

The  schirrhus  of  older  pathologists,  the  only  new  growth  designated 
by  them  as  cancer ;  other  equally  and  still  more  malignant  formations 
being  by  them  divided  into  sarcoma  and  fungus.  It  is  upon  the  whole 
the  most  compact  in  texture,  and  therefore  the  hardest  of  cancer-growths. 
Hence,  the  expression  scirrhous  hardness,  formerly  employed  to  denote 
in  an  organized  product  a  resistance  analogous  to  that  of  fibro-cartilage. 

In  a  parenchyma  like  that  of  the  mammary  gland,  scirrhus  commonly 
appears  as  a  clavate,  gibbous,  indistinctly  lobulated,  somewhat  branched, 
not  sharply  defined,  very  hard,  grayish,  or  bluish-gray  new  growth, 
which  has  the  faculty  of  dragging  down  surrounding  textures  upon  itself, 
is  of  moderate  size,  of  from  a  walnut  to  a  duck's  egg,  is  heavy  in  pro- 
portion to  its  density  of  texture,  and  creaks  under  the  knife. 

Several  deviations,  to  be  hereafter  specified,  here  present  themselves. 
We  shall,  however,  limit  ourselves  in  this  place  to  the  statement  that  the 
density  of  the  fibrous  texture,  sufficiently  cognizable  with  the  naked  eye, 
as  also  the  hardness,  do  not  always  attain  the  presumed  high  grade. 
Under  certain  conditions,  scirrhus  becomes  tolerably  lax  and  succulent. 

On  a  more  minute  examination,  the  principal  mass  appears  to  consist 


FIBRO-CARCINOMA.  205 

of  a  fibrous  texture,  imbedded  in  which  are  embryonic  elements,  in  the 
shape  of  nucleus  and  cell.  The  former  gives  it  the  impress  of  fibrous 
cancer,  and  determines  its  density  and  hardness.  The  greater  the 
number  of  the  embryonic  elements,  the  more  does  its  fibrous  texture 
serve  as  a  stroma  for  a  constituent,  whose  preponderating  mass  alters 
and  determines  its  characters. 

The  fibrous  groundwork  presents  manifold  differences  with  respect  to 
the  form  and  the  arrangement  of  the  fibres. 

1.  Very  commonly  it  is  a  fibre  resembling  an  areolar  tissue-fibre  or 
fibril,  or  that  of  the  organic  muscles. 

2.  Sometimes  it  is  a  consolidated,  tolerably  transparent  blastema,  in 
the  act  of  splitting  into  fibres  and  fibrils,  and  presenting  a  fibrous  torn 
surface.     In  both  instances  there  is  an  accession  of  granule-  and  nucleus- 
fibres  in  various  numbers. 

3.  In  a  case  of  stomach-cancer  it  was  a  dense  felt  of  black,  branched, 
anastomosing  fibrils,  similar  to  the  fibrils  of  fibrin. 

With  respect  to  arrangement : 

1.  The  fibres  for  the  most  part  point  in  one  direction  parallel  to  each 
other. 

2.  They  radiate  from  different  centres. 

3.  Considerable   columns   of  fibres   traverse  each   other   at  various 
angles,  so  that  upon  a  parallel-fibred  section  we  find  displayed,  here  and 
there,  the  stumps  of  transversely  and  obliquely  divided  fasciculi. 

4.  The  alveolar  fibre  arrangement  is  very  frequent. 

The  embryonic  elements  consist  of  nucleus  and  cell.  The  former  are 
often  very  numerous,  as  spherical,  shining  nuclei,  furnished  with  black 
contours.  Not  rarely,  indeed,  the  transparent  nature  of  crude,  cancer 
blastema  makes  it  appear  as  if  the  cancer  consisted  exclusively  of  these 
nuclei. 

The  cells  present  many  points  of  difference. 

They  are  round,  or  angular,  ganglion-globule-like,  or  again  wedge- 
shaped,  caudate,  &c. 

There  are  often  present  parent-cells,  which  become  developed  into 
alveoli ;  and  upon  a  cut  surface  we  meet  with  these,  visible  to  the  naked 
eye,  in  the  shape  of  prominent,  transparent  vesicles,  imparting  to  fibro- 
carcinoma  the  aspect  of  a  glandular  structure.  Bloodvessels  are  not 
wanting  in  scirrhus,  although  their  abundance  is  not  very  great.  Lob- 
stein  is  wrong  in  asserting  these  growths  to  be  non-vascular. 

Although  the  mass  of  fibro-carcinoma  is  not  altogether  dissolved  by 
boiling,  it  yields,  nevertheless,  a  notable  amount  of  gluten.  Compared 
with  medullary  cancer,  it  contains  a  smaller  proportion  of  fat  (accord- 
ing to  Martigny,  a  soft  fat ;  according  to  Breschet,  cholesterine). 

Acetic  acid  certainly  does  (although  denied  by  Muller)  render  the 
cells  more  limpid,  throwing  nuclei  and  nucleus  corpuscles  with  black 
contours  and  some  little  shrivelling,  more  into  relief. 

No  other  cancer  possesses,  in  so  high  a  degree  as  the  fibrous,  the  ten- 
dency to  condense  and  corrugate  the  textures,  in  which  it  has  taken  up 
its  seat,  or  to  drag  down  upon  itself  contiguous,  especially  if  they  be 
membranous,  parts.  The  invariable  consequence  is  the  wasting  of  the 
cancerous  organs,  and  the  shortening,  with  consolidation,  of  implicated 


206  FIBRO-C  ARCINOMA. 

membranous  formations.  Fibro-carcinoma  is  slow  of  growth,  and  slower 
in  proportion  as  the  fibrous  character  predominates  in  its  fabric.  It  will 
thus  vegetate  long,  without  producing  any  visible  cachexia,  provided  it 
do  not  interfere  with  the  function  of  any  vital  organ,  and  provided  it 
remain  solitary.  A  more  rapid  growth  is  always  conditional  upon  an 
overpowering  development  of  embryonic  elements  out  of  fluid  blastema  ; 
which  latter,  in  the  inverse  ratio  of  its  plasticity,  relaxes  the  texture  of 
the  scirrhus,  drenches  it,  and  causes  it  to  swell.  It  is  often  of  a  medul- 
lary (encephaloid)  character,  giving  rise  to  a  combination  of  fibrous  with 
medullary  cancer,  in  the  shape  of  a  more  or  less  intimate  blending  of 
the  two.  With  this,  there  is  always  a  simultaneous  increase  of  vascu- 
larity  in  the  cancer-parenchyma,  hypersemious  tumefaction,  and  inflam- 
mation ;  frequently,  also,  the  development  of  a  reticulum. 

The  presence  of  this  reticulum  changes  fibrous  cancer  to  that  form 
which  Johannes  Muller  has  designated  carcinoma  reticulare  or  reticula- 
tum.  That  is  to  say,  we  conceive  ourselves  to  be  warranted  by  experi- 
ment in  assuming  the  latter  to  be  fibrous  cancer,  plus  the  reticulum, — 
fibrous  cancer  in  the  aforesaid  progress  of  rapid  and  redundant  growth, 
and  incontinently  passing  into  congestion  and  inflammation.  Its  form- 
elements  are  identical  with  those  of  pure,  fibrous  cancer ;  although  the 
embryonic  elements  and  bloodvessels  predominate.  The  capacious  cells 
and  membrane-clad  cavities  met  with  occasionally  in  carcinoma  reticu- 
latum  by  Johannes  Muller,  are  probably  nothing  more  than  the  follicles 
of  an  alveolar  texture  that  has  invaded  the  fibro-carcinoma ;  such  follicles 
being  replete  with  the  substance  of  the  reticulum  as  a  product  of  inflam- 
mation. This  so  modified  fibro-carcinoma  frequently  occurs  in  the 
mammary  gland,  attaining,  for  the  reasons  stated,  a  greater  volume  than 
pure,  fibrous  cancer. 

Fibrous  cancer  occurs  (primitively  and  in  a  developed  form),  in  the 
mammary  gland ;  in  the  stomach,  perhaps,  still  more  frequently  ;  in  the 
colon;  in  the  submucous  areolar  tissue; — more  rarely  in  the  vaginal 
portion  of  the  uterus,  upon  serous  membranes,  and  in  the  subserous 
areolar  tissue.  Again,  as  an  expansive  degeneration  of  the  omentum 
and  of  the  mesentery ;  in  the  salivary  glands ;  in  the  fibrous  tunic  of  the 
bronchia.  In  several  of  these,  as  well  as  in  other  structures, — for  ex- 
ample, the  ovaries,  the  brain, — there  occur  cancerous  growths  of 
embryonic  composition,  and  in  all  likelihood  of  fibro-cancerous  nature. 

With  respect  to  shape,  fibrous  cancer  in  and  upon  membranous  struc- 
tures deviates  from  the  clavate  form  before  described.  In  the  stomach, 
for  instance,  it  represents  degenerations,  spreading  along  the  course  of 
the  submucous,  areolar  stratum,  and  only  here  and  there  swelling  into 
knobbed  projections ;  whilst  in  the  intestine  it  assumes  the  annular 
shape.  Upon  serous  membranes,  the  pleura  for  example,  it  sometimes 
occurs  as  a  fibroid  exudate,  that  is,  as  a  densely  fibrous,  whitish,  sha- 
greened  mass  of  unequal  thickness,  branching,  as  if  outpoured,  or 
dropped  here  and  there,  over  the  surface. 

In  the  bones  it  appears  in  the  shape  of  roundish  knobs,  imbedded  in 
the  diploe  of  the  cylindrical  bones,  over  which  the  compact  covering 
plate  becomes  wasted  by  compression,  giving  occasion  to  spontaneous 
bone  fractures. 


MEDULLARY    CARCINOMA.  207 

In  the  frequent  cases  of  cancer  of  the  stomach  we  have  the'best  op- 
portunities for  studying  the  character  of  the  cancerous  degeneration  of 
muscular  tissues.  It  consists  in  a  development  of  white  interfascicular 
striae,  imparting  to  the  fleshy  tunic  a  white-celled  aspect.  The  white 
striae  consists  of  accumulations  of  nuclei,  cells,  and  lastly,  fibres,  which 
receive  and  so  to  speak  encapsule  the  swollen,  reddish,  or  yellowish  red, 
exsanguine  muscle-substance.  The  formation  of  these  septa  multiplies, 
and  they  increase  in  volume  until  the  muscle  has  entirely  given  way  and 
perished. 

Fibro-carcinoma  is,  for  the  most  part,  the  primitive  cancer  in  the 
organism,  and  very  rarely  indeed  the  secondary.  The  cancer-growths 
consecutive  to  it  have,  in  proportion  as  they  multiply,  more  and  more 
the  character  of  the  medullary  form.  Even  the  occasionally  more  rapid 
development  of  fibre-carcinoma  takes  place  under  the  supervention  of 
medullary  carcinoma,  and  the  afiection  of  the  implicated  lymphatic 
glands  occurring  in  the  consecutive  series  is  of  the  same  medullary  cha- 
racter. In  like  manner  the  extirpation  of  fibrous  cancer  is  generally 
followed  by  medullary  growth. 

In  conclusion,  we  would  advert  to  certain  malignant  accumulations, 
proved  by  antecedent  circumstances  to  be  undoubtedly  cancerous.  These 
infest  bone,  the  ovaries,  again  the  mediastina,  the  retro-peritoneal  space, 
lastly,  the  intermuscular  areolar  tissue ;  and  they  are  distinguished  for 
the  great  bulk  to  which  they  attain.  As  regards  their  elementary 
fabric,  they  are  almost  always  embryonic  structures,  that  is  to  say,  they 
consist  of  nuclei  and  spindle-shaped  or  caudate  cells,  which  last,  by  their 
arrangement,  impart  to  the  whole  the  semblance  of  fibrillation.  The 
intercellular  substance  (blastema)  is  very -scant;  and  the  heterologous 
mass  is  consequently  very  dense  and  firm.  They  are  to  be  regarded  on 
the  one  hand  as  embryonic  fibre-cancers ;  on  the  other,  as  kindred  with 
the  firmer  varieties  of  medullary  cancer. 

3.    MEDULLARY   CARCINOMA. 

In  every  way  the  most  malignant  heterologous  growth,  described  by 
Burns  as  spongioid  inflammation  ;  by  Hey,  and  afterwards  by  Wardrop, 
M  fungus  hcematodes  ;  by  Abernethy  as  medullary  sarcoma  ;  by  Monro 
as  fisli-testicle-like  (soft  roe-like)  turn  or  ;  by  Laennec  as  encephaloide  ; 
by  Maunoir  v&fongue  medullaire.  All  these  appellations  serve  well  to 
designate  the  external  characters  of  this  new  growth  ;  that  of  fungus 
haematodes  being,  however,  applicable  to  a  combination  of  this  malignant 
growth  with  redundant  vascularity.  (See  New  Growth  of  Bloodvessels.) 

If,  for  the  sake  of  unity  and  clearness,  we  select  for  our  principal 
delineation,  medullary  carcinoma  in  its  most  marked  form,  and  with  all 
the  attributes  of  the  most  malignant  cancer,  we  must  preface  the  descrip- 
tion by  admitting  that  in  the  instance  of  no  other  cancer  are  more  varia- 
tions from  this  cardinal  character  cognizable. 

In  this,  its  exquisite  form,  medullary  carcinoma  certainly  does  offer  a 
striking  resemblance  with  the  brain-medulla  of  younger  individuals,  or 
with  the  testicle  of  fishes ;  namely,  a  soft,  semi-fluid,  when  present  in 
large  quantity,  fluctuating,  white,  or  under  certain  conditions,  reddish- 


208  MEDULLARY    CARCINOMA. 

white  or  gray,  yellowish-white,  red  or  russet,  or  even  in  various  degrees 
blackened,  heterologous  mass. 

As  an  independent  tumor,  its  cut  surface  exhibits  either  a  perfectly 
homogeneous  or  else  a  variously  cancellated,  lobulated,  more  or  less  dis- 
tinctly fibrous  structure.  When  pressed  or  scraped,  the  cut-surface  also 
yields  a  perfectly  homogeneous  substance  out  of  a  parenchyma  which 
mingles  with  water  to  a  uniform  mass.  Or,  again,  the  entire  mass 
separates  into  a  looser  medullary  constituent,  and  into  another  more 
consistent,  which  furnishes  a  sort  of  stroma  for  the  former,  and  appears 
as  a  more  or  less  fibrous  or  villo-membranous  framework.  The  relative 
quantity  of  both  varies  considerably. 

These  relations  are  subject  to  great  variations,  determined  for  the 
most  part,  by  the  degree  of  consistency  of  the  heterologous  growth  as 
cognizable  with  the  naked  eye.  There  are  some  growths  of  this  kind 
which  recede  so  far  from  the  medullary  character,  as  hardly  at  all  to 
tally  with  the  description  above  given  of  medullary  carcinoma.  Still, 
the  occasional  blending  or  interlacing  of  such  deviating  structures  with 
exquisite  medullary  carcinoma,  in  one  and  the  same  organ,  the  em- 
bryonic condition  of  their  elements,  their  rapid  growth,  and  their  volu- 
minous character,  seem  to  justify  their  mention  in  this  place. 

Thus  there  are,  on  the  one  side,  medullary  carcinomata  of  almost 
cream-like  fluidity,  or  which,  infiltrated  into  the  textures,  into  the 
medullary  system  of  the  bones,  or  into  the  sheaths  of  organs  after  the 
destruction  of  their  parenchyma, — for  example,  the  neurilemma  of  the 
pituitary  gland,  the  capsule  of  the  spleen,  &c., — resemble  a  milky  juice. 
No  stroma  enters  into  their  composition.  On  the  other  side,  there  are 
congenerous  growths — heterologous  masses,  very  commonly  regarded  as 
medullary  carcinoma  in  a  crude  state,  that  is,  in  a  primitive  stage  of 
the  true  medullary  encephaloid — which,  in  point  of  consistency,  do  not 
yield  to  the  fibroids,  to  fibro-cartilage.  Amongst  these  denser  masses 
there  is  one  particularly  remarkable — namely,  an  often  very  volumi- 
nous, in  appearance,  and  also  in  reality,  unevenly-lobulated,  homoge- 
neous, whitish,  or  yellowish-white,  heterologous  mass,  which  offers  a 
striking  analogy  with  the  virgin  mammary  gland,  especially  in  point  of 
firmness  and  of  elasticity.  It  is  probably  to  this  that  Abernethy  applied 
the  term  mammary  sarcoma.  Others  present  the  aspect  of  a  glandular 
structure  ;  for  example,  of  the  texture  of  the  salivary  glands,  or  of  the 
cortical  substance  of  the  kidney. 

Lastly,  the  vast  difference  in  bloodvessel-formation,  referable  to  the 
structure  of  medullary  carcinoma,  is  perceptible  even  to  the  naked  eye. 
In  no  other  parenchyma  does  it  appear  so  frequently  in  redundance  as 
in  medullary  carcinoma.  Conformably  herewith  none  is  so  susceptible 
of  hypersemia,  of  tumefaction,  and  of  rapid  growth  ;  in  none  do  hemor- 
rhage (apoplexy)  and  inflammation  so  readily  occur — processes,  upon 
which  the  anomalous  coloration  of  genuine  white  medullary  carcinoma 
obviously  depends. 

The  differences,  however,  discoverable  with  the  naked  eye  in  carci- 
noma, are  slight  compared  with  those  revealed  in  the  elementary  texture 
of  medullary  carcinoma,  with  the  aid  of  a  magnifying  power. 

They  are  divisible  into  those  recognized  by  the  naked  eye  as  compo- 


MEDULLARY    CARCINOMA.'  209 

nents  of  medullary  matter,  and  into  those  which,  at  the  same  time, 
present  an  intercellular  substance, — a  stroma. 

With  reference  to  the  former,  there  are  medullary  carcinomata. 

(a.)  Consisting  of  granulated  cells  with  a  more  or  less  distinct  nucleus, 
and  resembling  pus-globules. 

(b.)  Consisting  of  smaller  and  greater,  granulated,  round,  or  angular, 
protuberant  cells,  more  or  less  resembling  the  cells  of  tessellated  epithe- 
lium, the  hepatic  cells,  the  ganglion  globules,  and  provided  with  one  or 
several  nuclei. 

(c.)  Consisting  of  spindle-shaped  and  caudate,  nucleated  cells,  fibre- 
cells,  amongst  which  are  many  others,  both  spherical  and  oval. 

(d.)  Consisting  of  elliptical  corpuscles,  of  yJu  to  5^  of  a  millimetre  in 
circumference,  and  furnished  with  one  or  two  nucleoli.  They  have  the 
significance  of  a  (heteroplastic)  transcendent  development  of  cell  nuclei. 

(e.)  Consisting  of  spherical  or  oval  corpuscles  corresponding  in  size 
and  tendency  with  the  cell-nucleus. 

(/.)  Consisting  of  elementary  granules  down  to  the  finest  molecule- 
mass,  with  scanty  nucleus  formations  in  progress  of  development. 

(g.}  A  further  element  concurrent  with  those  specified  at  5,  are  pouch- 
like  formations  (see  Metamorphosis  of  Blastema),  and  chiefly  the  parent- 
cell,  which  often  constitutes  a  prominent  element  in  medullary  cancers. 
It  forms  here  again  the  groundwork  for  the  alveolar  textural  type  of 
medullary  cancer. 

These  elements  occur  predominantly,  it  may  be,  in  the  one  or  the 
other  form,  but  intermingled  with  others.  Viewed  with  the  naked  eye, 
the  elementary  composition  of  a  texture  is,  even  to  the  well  initiated,  a 
matter  rather  of  conjecture  than  of  any  certainty.  The  consistency  and 
density  of  a  texture  may  vary  infinitely,  being  dependent  upon  the  cha- 
racter of  the  intercellular  substance.  It  is  only  where  there  is  the  ap- 
pearance of  fibrillation  that  we  may  perhaps  infer  a  composition  of 
spindle-shaped  or  caudate  cells. 

Differences  more  important  affect  the  character  of  the  intercellular 
substance,  and  of  a  stroma  in  which  the  elements  adverted  to  lie  imbed- 
ded. This  stroma  is  developed  either  out  of  those  elements  themselves, 
which,  according  to  the  laws  of  the  cell  theory,  form  into  a  fibrous 
skeleton  work ;  or  else  it  springs  immediately  out  of  a  consolidated, 
amorphous,  intercellular  substance.  Both  together  occasion,  in  medul- 
lary carcinoma,  a  special  structure  manifest  to  the  naked  eye,  in  the 
shape  of  a  variously  disposed  fibrillation  and  lobulation,  &c.,  the  cha- 
racter of  which  so  greatly  modifies  the  consistency  of  the  heterologous 
growth. 

In  this  regard,  we  have  the  following  forms,  some  more  or  less  cogni- 
zable with  the  naked  eye. 

(a.)  A  medullary  carcinoma,  with  an  amorphous  fluid,  or  semi-fluid, 
intercellular  substance.  The  aforesaid  elements  vegetate  in  a  thin  or  a 
thickish  medullary  juice.  It  is  represented  in  the  very  lax,  milky  or 
cream-like  encephaloid  cancer. 

(b.)  A  medullary  carcinoma,  with  a  solidified,  amorphous,  or  else 
striated,  indefinitely  fibrous,  intercellular  substance,  interspersed  with 
roundish  and  fibro-elongated  nuclei. 

VOL.  I.  14 


210  MEDULLARY    CARCINOMA. 

(<?.)  Medullary  carcinoma,  with  a  stroma  consisting  of  fibre-cells 
(spindle-shaped,  caudate)  arising  out  of  the  development  of  the  elements 
of  the  medullary  substance  itself,  with  consumption  of  the  intercellular 
substance,  and  condensation  of  the  heterologous  growth. 

(d.)  Medullary  cancer  with  a  delicate  hyaline,  structureless,  or  else 
an  opaque,  striated,  membranous  stroma,  studded  with  elementary 
granules  and  nucleus  formations,  or  fibril lated  like  areolar  tissue  ;  which 
stroma,  at  the  same  time,  forms  the  groundwork  for  the  vascularization 
of  the  alien  growth.  Its  interspaces  are  filled  with  a  loose,  fluid  medul- 
lary matter,  and  it  is  easily  thrown  into  relief  if  the  tumor  be  scraped, 
pressed,  or  simply  steeped  in  water.  In  villous  cancer  this  stroma  ap- 
pears developed  into  a  main  constituent. 

(e.)  Medullary  carcinoma  with  a  more  or  less  developed  fibrous  stroma, 
whose  fibre-elements,  upspringing  from  a  solidified  blastema,  now  re- 
semble fibro-cellular  tissue,  now  organic  muscle-fibre.  It  represents 
either  a  scaffold-work  or  a  stellate  structure,  the  gaps  being  filled  up 
with  embryonic  elements.  Even  with  the  naked  eye  it  is  discernible  as 
denser  striae,  disposed  as  aforesaid,  and  remarkable  for  their  whiteness 
and  their  tendon-like  lustre.  This  stroma  has  frequently  the  signifi- 
cance of  fibrous  cancer  blended  with  medullary.  It  is,  however,  often 
enough  an  innocent  fibroid  growth,  which  ^may  very  possibly  become  the 
seat  of  so-called  ossification  (bony  concretion).  Hence  the  extraordinary 
phenomenon  of  medullary  cancer  becoming  traversed  by  a  concrete 
skeleton-work,  in  the  midst  even  of  soft  parts. 

This  seems  the  proper  place  to  take  into  consideration  another  combi- 
nation with  a  benign  new  growth  in  the  shape  of  a  stroma,  namely,  that 
writh  normal  bone-texture. 

A  normal  bone-texture  occurs  very  frequently  in  medullary  cancer 
affecting  bones,  as  a  thorny  or  stellate  skeleton  or  stroma.  This  is, 
however,  generally  limited  to  the  base  of  the  alien  growth.  Greater  in- 
terest attaches  to  a  medullary  carcinoma,  possessing  throughout  a  firm 
bony  stroma,  which,  as  a  finely  cancellated  diploe,  receives  into  its 
cancelli  the  soft  parenchyma  of  the  medullary  cancer,  to  which  it  bears 
a  relation  similar  to  that  of  bone  to  its  normal  medulla.  This  growth 
certainly  affects  bones  and  their  vicinity,  although  not  exclusively.  It 
is  what  Johannes  Miiller  termed  malignant  osteoid.  The  bony  texture 
entering  so  largely  into  its  composition,  is  a  very  remarkable  pheno- 
menon, but  its  nature  is  simply  that  of  a  benign  stroma  for  the  reception 
of  a  cancerous,  soft  parenchyma. 

An  important  part  is  assigned,  in  medullary  carcinoma,  to  the  parent- 
cell,  and  to  the  alveolar  textural  type  resulting  from  it.  We  have  often 
examined  medullary  carcinomata  which  mainly  consisted  of  parent-cells. 
One  consisted  entirely  of  parent-cells,  and  being  in  the  progress  of  fatty 
conversion,  it  presented  a  very  peculiar  aspect.  Numerous  liver  cancers 
were  found  to  consist  of  a  fish-roe-like  accumulation  of  yellow,  poppy- 
grain-sized  granules — parent-cells,  replete  with  fat-containing  filial  cells 
— loosely  connected  together  by  a  liquid,  lardo-glutinous,  yellowish-brown, 
intercellular  substance. 

Both  forms  of  the  alveolar  texture  occur  in  medullary  cancer,  the  true 
alveolus,  and  also  the  aciniform,  excavated  body.  Both,  more  especially, 


MEDULLARY    CARCINOMA.  211 

however,  the  latter,  determine  the  likeness  of  many  medullary  cancers 
with  gland-textures.  Both  may  coexist  independently  of  each  other,  or 
the  second  vegetate  as  an  endogenous  growth  within  the  alveolus. 
Medullary  carcinoma  occurs  no  less  frequently  as  cysto-carcinoma. 

Upon  the  dura  mater,  heterologous  formations  are  not  unfrequent, 
which,  closely  resembling  granular  cortical  substance  of  the  kidney,  con- 
sist of  spherical  or  roundish  rolls  of  caudate  cells,  imbedded  in  a  layer 
composed  of  the  same  elements.  They  are  gorged  with  a  white  medul- 
lary juice,  are  for  the  most  part  considerably  vascular,  and  of  a  turgid, 
soft  consistence. 

Medullary  cancer  consists  mainly  of  albumen,  with  fat,  according  to 
Wiggers  a  phosphorus-holding  fat  (brain-fat),  according  to  Gugert  cho- 
lesterine,  and,  as  Eichholtz  contends,  with  pyin. 

Medullary  carcinoma  ordinarily  assumes  the  form  of  roundish  tumors; 
not  rarely,  however,  both  primarily  and  consecutively,  that  of  infiltra- 
tion into  the  parenchyma  of  every  variety  of  organ.  To  the  naked  eye, 
the  tumors  often  seem  sharply  sundered  from  the  surrounding  textures. 
Nevertheless,  the  impossibility  of  dissecting  them  out,  without  injury  to 
those  textures,  and  a  narrower  scrutiny,  teach  us  that  they  penetrate 
into  neighboring  textures,  and  moreover,  that  they  grow  in  suchwise  as 
to  infiltrate  and  destroy  the  textures  in  their  immediate  circumference. 
In  other  cases,  however,  they  are  capable  of  being  shelled  out  of  an  organ, 
Laving  a  very  delicate,  areolar  tissue-like,  vascular  sheath.  Such 
growths  are  generally  furnished  with  a  membranous  stroma,  are  more  or 
less  distinctly  lobulated,  grow  independently,  and  simply  jostle  the  tex- 
tures out  of  their  place. 

Medullary  cancer  in  the  one  case  grows  to  an  enormous  volume,  in 
the  other  case  is  remarkable  for  its  numerical  dissemination.  Its  increase 
in  volume,  especially  when  rapid,  takes  place  through  the  accession  of 
embryonic  elements.  Hence  the  circumstance  that  old  medullary  carci- 
nomata  which  suddenly  undergo  great  augmentation  of  volume,  have,  at 
their  base  only,  a  solid  and  textural  stroma,  or  it  may  be  a  bony  skeleton. 
Medullary  carcinoma  is,  both  in  its  development  and  in  its  subsequent 
course,  the  most  acute  of  all  cancers.  As  a  solitary  growth  in  the 
organism,  it  arrives  very  rapidly  at  its  full  volume,  and  throws  out  a 
multitude  of  secondary  tumors  with  the  same  celerity,  not  unfrequently 
under  the  accompaniment  of  very  acute  typhoid  fever.  The  more  hurried 
its  development,  the  more  does  the  embryonic  form  (elementary  granule, 
nucleus,  fluid  intercellular  substance)  of  its  elementary  composition,  that 
of  genuine  encephaloid,  predominate.  Wherever  cancer-production  is 
acute,  its  form  is  the  medullary. 

Conformably  with  this,  every  other  cancer,  goaded  into  redundant 
growth,  degenerates  into  the  medullary,  that  is,  enters  into  combi- 
nation with  the  latter,  the  new  accession  being  the  medullary.  The 
fungus  upspringing  from  the  ulcerating  base  of  a  cancer,  is  in  its  nature 
medullary.  Every  consecutive,  every  general,  cancer-production  is  in- 
variably medullary,  nor  is  there  any  organ  in  which  medullary  carcinoma 
does  not  occur,  either  primitively  or  consecutively,  as  part  and  parcel  of 
general  cancer  production. 

In  point  of  fact,  medullary  carcinoma  occurs  in  organs  in  which  no 


212  MEDULLARY    CARCINOMA. 

other  cancer,  least  of  all  fibrous  cancer,  ever  occurs ;  as  in  the  liver,  the 
kidneys,  the  lungs,  the  testicles,  the  lymphatic  glands. 

In  the  bones,  medullary  cancer  is  frequently  distinguished  by  a 
lamina-stellate,  thorny  bone-skeleton,  the  form  often  obviously  depend- 
ing upon  the  nature  and  arrangement  of  the  stroma.  Sometimes  it 
causes  the  bone  to  rise  up  into  a  bone-ca,psule ;  more  frequently,  how- 
ever, it  dissipates  it  into  a  voluminous  honeycomb  mass. 

In  medullary  carcinoma  the  cancer-crasis  has  attained  its  highest 
grade.  It  experiences  a  further  augmentation  through  infection, — 
through  reception  of  this,  the  most  readily  absorbed  cancer  blastema, 
into  the  lymphatics  and  bloodvessels.  The  products  of  inflammation 
placed  under  its  influence  are  eminently  albuminous,  white,  opaque 
exudates,  and  these  become  developed  into  medullary  cancer,  upon  serous 
membranes,  or  as  cancerous  lung  hepatization,  and  the  like.  The  same 
thing  happens  with  respect  to  coagula  within  the  vascular  system,  both 
in  the  greater  vessels  and  in  the  capillary  system ;  by  dint  of  an  aliena- 
tion of  the  fibrin,  they  bear  evident  marks  of  the  cancerous  character — 
cancerous  phlebitis,  capillary  phlebitis  (deposit). 

We  cannot  subscribe  to  the  assumption  of  regular  stages  of  medullary 
cancer,  of  a  stage  of  crudity,  of  softening,  of  ulceration,  &c.,  these  being 
conditions  not  correlated  by  any  necessary^  causal  links. 

That  which  is  regarded  as  crude  medullary  cancer,  is  the  variety 
furnished  with  a  consolidated  intercellular  substance.  Softening  ob- 
viously characterizes  the  form  of  medullary  cancer  luxuriating  as  the 
true  encephaloid,  and  it  attaches  equally  to  that  which  originates  at 
once  as  such.  Lastly,  the  ichorous  and  ulcerous  destruction  of  the  struc- 
ture is  a  consequence  of  its  inflammation,  that  is,  of  accidental  disease  of 
the  tumor. 

Medullary  carcinoma  frequently  destroys  life  as  a  consequence  of  its 
surpassing  growth,  either  as  a  solitary  alien  formation,  or  as  one  dis- 
tributed over  several  organs, — through  cachexia  and  exhaustion,  through 
hindrance  to  the  function  of  important  organs  ;  for  example,  of  the 
digestion,  of  the  larger  veins, — the  vena  cava,  by  its  closure ;  again 
through  hemorrhage ;  finally,  through  inflammation  and  ulceration,  often 
under  the  symptoms  of  cancerous  infection  of  the  blood. 

The  substance  constituting  the  reticulum  occurs,  especially  in  the 
softer  forms  of  medullary  carcinoma,  in  large  accumulated  masses.  In 
the  forms  furnished  with  a  fibrous  or  membranous  stroma  it  follows  for 
the  most  part  the  distribution  of  the  latter,  and  therefore  of  its  blood- 
vessels. 

Contradictory  as  it  may  seem,  after  what  has  been  stated,  in  no  cancer 
is  a  spontaneous  or  natural  process  of  cure  brought  about  so  frequently 
as  in  the  medullary. 

Such  a  process  is  the  sudden  and  rapid  destruction  of  the  cancer  by 
ulceration  and  necrosis,  as  observed  not  unfrequently  in  the  dead  subject, 
in  medullary  cancer  of  the  womb.  Such  a  process,  again,  is  the  meta- 
morphosis described,  under  the  general  heading  of  "Cancer,"  as  saponi- 
fication  and  incrustation.  Moreover,  it  is  known  as  a  fact,  that  medul- 
lary carcinoma  in  the  subcutaneous  fat-layer  will  disappear  through 
resorption,  and  return  again. 


CAXCER     MELANODES.  213 

With  reference  to  the  fungus  hsematodes  of  Wardrop,  and  the  medullary 
carcinoma  of  Abernethy,  we  feel  compelled  to  subscribe  to  Walter's 
verdict,  namely,  that  they  are  identical.  For  we  have  always  found  the 
former  to  resolve  itself,  when  closely  examined,  into  medullary  carcinoma 
with  luxuriating  vascularity.  Assuming,  therefore,  the  term  "  fungus 
hsematodes"  to  designate  a  mere  accidental  condition  of  medullary  carci- 
noma, there  might  be  no  impropriety  in  abandoning  it,  or  in  under- 
standing by  it  only  a  highly  vascularized  medullary  carcinoma. 

On  the  other  hand,  it  is  requisite  to  bear  in  mind  that  which  we  have 
stated  under  the  head  of  bloodvessel  formation,  namely,  that  assuredly 
there  are  alien  growths,  which,  although  primitively  mere  bloodvessel 
luxuriations,  may  subsequently  combine  with  cancer,  and  this  possibly 
without  any  concurrent  anomaly  of  the  general  crasis,  through  mere 
impairment  of  the  blood  held  within  their  own  capillary  system.  We 
must  here  once  more  refer  to  the  results  of  Van  der  K  oik's  injections  of 
the  growths  in  question,  which  induced  him  to  discriminate  between 
fungus  haematodes  and  medullary  carcinoma. 

That  medullary  carcinoma  has  some  sort  of  affinity  to  the  medulla  of 
the  nervous  system,  appears,  not  alone  from  its  general  aspect  and 
chemical  composition,  but  also  from  the  fact  that,  in  medullary  cancer 
of  the  eyeball,  the  tumor  springs  from  either  the  retina  or  the  optic 
nerve,  and  that  nerves  speedily  perish  within  the  range  of  medullary 
tumors. 

To  medullary  carcinoma  we  shall  annex,  as  varieties,  certain,  growths 
which  bear  an  affinity  to  it. 

(a.)   CANCER  MELANODES. 

The  entrance  of  pigment  into  the  composition  of  any  cancer  converts 
it  into  cancer  melanodes.  Nowhere,  however,  does  this  substance  occur 
in  so  marked  a  degree  as  in  a  cancer  closely  resembling  the  medullary. 
It  may  indeed  be  said,  that  cancer  melanodes  (so-called  malignant  mela- 
nosis)  is  but  a  medullary  carcinoma  modified  by  pigment,  an  idea  pro- 
mulgated by  Meckel,  von  Walther,  and  others,  in  their  day. 

Cancer  melanodes,  as  an  independent  tumor,  presents  most  of  the 
physical  aspects  of  medullary  carcinoma.  Its  cut  surface  appears  to 
the  naked  eye  either  homogeneous,  or  fibrous,  or  lobulated,  and  of  a 
more  or  less  firm  and  brain-like  consistence.  A  closer  inspection  of  it 
reveals  elementary  granules,  nuclei,  cells  of  spherical  or  oval,  caudate, 
elongated,  angular  shape,  and  along  with  these  the  most  varied  inter- 
cellular substances  and  stromata.  Melanotic  cancer  imitates  most  com- 
monly the  encephaloid  variety  of  medullary  carcinoma,  with  round  and 
caudate  cells,  and  a  membranous — a  villo-membranous — stroma. 

These  alien  growths  are  chiefly  marked  by  their  black  or  brown-black, 
brown,  bronze-green,  or  rust-brown  coloration.  The  first  glance  at 
these  often  numerous  tumors  generally  suffices  to  show  that  the  color  is 
merely  accessory.  For,  amongst  thoroughly  tinged,  we  meet  also  with 
perfectly  colorless,  white,  heterologous  growths  ;  and  again  between  the 
two  extremes  others  pigmented  in  the  most  various  forms,  in  dotted  or 


214  CANCER    MELANODES. 

stellate  patches,  or  in  ramifying  anastomosing  strias.  The  white  growths 
are  recognized  at  once  as  genuine,  ordinary,  encephaloid  cancer. 

A  minute  examination  detects,  according  to  circumstances,  a  greater 
or  lesser  proportion  of  pigment,  and,  even  in  the  blackest,  elements 
enough — cells  and  intercellular  substance — free  from  pigment. 

Pigment  occurs  free  or  inclosed  in  cells,  in  all  the  forms  enumerated 
under  that  heading.  Its  basis  is,  as  there  taught,  and  especially  as  the 
examination  of  acutely  produced  or  redundantly  growing  cancer  mela- 
nodes  incontestably  proves,  hsematin  in  a  free  and  dissolved  state,  or 
else  blood-globules,  with  their  pigment,  in  substance.  In  the  latter 
case,  the  alien  growth  resembles  a  hemorrhagic  effusion,  in  which  are 
found  along  with  the  blastema  the  elements  of  medullary  cancer  in 
various  phases  of  coloration  and  of  conversion  into  pigment. 

Chemical  analysis  must  needs  detect  the  constituents  of  medullary 
carcinoma,  and  the  pigment  with  its  base.  Barruel  and  Henry  have 
discovered,  in  the  melanosis  in  man,  hsematin,  fibrin,  three  kinds  of  fat, 
a  considerable  amount  of  phosphate  of  lime,  and  iron. 

Like  medullary  carcinoma,  cancer  melanodes  is  found  to  infiltrate  the 
textures  of  parenchymata,  as  also  of  membranous  parts,  the  dura  mater 
for  instance. 

By  reason  of  its  pigment,  melanotic  cancer  may  be  studied  at  its  out- 
set in  very  small  point-like  portions,  which*  under  a  magnifying  power, 
appear  minutely  ramified. 

Like  genuine  medullary  cancer,  the  melanotic  often  attains  to  an  ex- 
traordinary circumference.  Its  simultaneous  occurrence  in  many,  if  not 
in  most  organs,  is,  however,  still  more  usual.  Its  multiplication  is  often 
very  rapidly  brought  about,  with  the  concurrence,  it  may  be,  of  acute 
typhoid  fever.  No  organ  is  exempt  from  the  disease.  Even  when  at- 
tacking all,  or  several,  organs  simultaneously,  it  may  grow  inordinately 
in  a  single  one  or  more  than  one,  in  which  case  the  liver  is  almost  always 
found  to  be  the  organ  of  predilection.  We  have  seen  it  in  the  brain 
and  about  the  nerves,  at  the  eyeball,  in  the  lungs,  in  the  thyroid  gland, 
in  the  liver,  spleen,  kidneys,  bones,  lymphatic  glands,  ovaries,  in  and 
beneath  the  intestinal  mucous  membrane,  between  the  mesenteric  layers, 
in  the  skin  and  subcutaneous  areolar  tissue,  upon  serous  membranes,  in 
the  dura  mater,  upon  and  within  the  heart. 

In  the  majority  of  cases,  cancer  melanodes  is  found  to  affect  middle- 
aged  or  still  older  individuals.  Both  we  ourselves  and  others  have  how- 
ever observed  it  with  little  less  of  frequency  even  in  youth. 

The  crasis  upon  which  cancer  melanodes  is  based,  is  without  doubt 
essentially  the  medullary.  The  pigment  has,  however,  still  to  be  ac- 
counted for.  A  special  dyscrasial  character  of  the  hsematin  and  of  the 
blood-globules  might  here  suggest  itself,  a  crasis  analogous  to  the  con- 
stitution of  the  portal  blood  with  a  continuous  excess  of  aged  and  spent 
blood-globules  which  have  reached  their  climax  of  coloration  in  a  defibri- 
nated  plasma,  the  ready  suscipient  of  hsematin.  Such  a  view  would 
find  support  in  the  cachexia  so  often  concurrent  with  melanosis,  and 
so  characteristic  of  a  predominant  venous  constitution,  with  a  vivid, 
brownish  coloration  of  the  common  integuments.  And  to  this  might  be 
added  the  fact,  that  cancer  melanodes  is  more  than  ordinarily  rich  in 


TYPHOUS     SUBSTAXCE.  215 

pigment  when  occurring  in  the  liver  and  the  choroid  plexus,  in  which, 
for  various  ends,  pigment  is  thrown  out  from  the  spent  blood-globules 
even  in  the  physiological  state. 

But,  apart  from  numerous  exceptions  in  this  last  respect,  we  must 
guard  against  overlooking  very  important  local  processes  in  cancer 
melanodes,  where  the  base  of  the  pigment  is  furnished,  not  by  the 
general  circulation,  not  by  haematin,  but  by  substantive  blood-globules. 
Here  the  question  is,  first,  whence  is  derived  the  blood  as  the  basis  of 
pigment  ?  and,  secondly,  what  causes  the  transmutation  of  the  blood  to 
pigment  ?  The  latter  question  is  the  more  pertinent  that  in  medullary 
carcinoma  hemorrhage  is  common  enough  without  any  entailment  of  the 
pigment  of  cancer  melanodes.  In  reply  to  the  first  query,  we  have  to 
express  a  well-substantiated  conviction  that  the  blood  furnishing  the  base 
of  the  pigment  in  cancer  melanodes  is  not — at  least  not  mainly — an  ex- 
travasate  out  of  a  perfected  system  of  bloodvessels ;  but  blood  newly 
formed  in  parent-cells,  and  transformed  into  pigment  either  within  these 
cells  or  upon  their  breaking  up. 

This  metamorphosis  within  parent-cells  engaged  in  a  process  of  radia- 
tion and  ramification  into  a  capillary  system,  explains  the  circumstance 
that  the  pigment,  in  its  first  manifestation  in  the  parenchyma  of  a 
genuine  white  medullary  carcinoma,  appears  in  the  form  of  finely 
branched  and  stellate  points  and  patches. 

Cancer  melanodes  generally  proves  fatal  in  its  excessive,  multiple  pro- 
duction, through  the  exhaustion  and  wasting  corresponding  to  such 
redundant  alien  growth.  In  rare  instances  cancer  melanodes  enters 
upon  a  process  of  ulceration,  and  kills  through  hemorrhage  or  simple 
exhaustion. 

TYPHOUS    SUBSTANCE. 

The  product  of  typhous  blood-stasis  deposited,  in  intestinal  typhus  in 
the  follicular  apparatus  of  the  bowel,  in  broncho-typhus  in  the  bronchial 
glands,  and  probably  in  plague-typhus  in  different  superficial  lymphatic 
glands,  appears  to  us  so  analogous  in  many  points  with  medullary  carci- 
noma that  we  do  not  hesitate,  in  accordance  with  an  opinion  long  enter- 
tained, to  award  it  a  place  here. 

Typhous  substance  appears,  in  extreme  cases  where  it  is  rapidly 
produced  under  violent  symptoms,  as  a  grayish  or  whitish  red,  or  a  gray, 
or  a  white,  lax, — in  the  mesenteric  glands  almost  diffluent, — fluctuating, 
medullary  substance,  wrhich,  in  its  external  features,  bears  the  most 
striking  similarity  to  encephaloid  cancer. 

This  typhous  substance,  after  abiding  for  a  certain  period  in  its  pri- 
mitive crude  state,  enters  into  a  process  of  loosening  up  and  sloughing, 
which  becomes  the  medium  of  its  removal  from  the  normal  textures.  In 
some  instances,  and  some  epidemics,  this  breaking  up  manifests  itself  as 
a  development  of  the  typhous  substance,  both  in  the  follicular  apparatus 
and  in  the  lymphatic  glands,  to  a  luxuriating,  bleeding,  partially 
necrosed,  fungoid  growth  (Hensinger's  muco-membranous  fungus).  The 
latter  in  particular,  offers  the  greatest  analogy  with  medullary  fungus. 

The  elementary  composition  of  the  typhous  substance  is  embryonic — 


216  VILLOUS    CANCER. 

elementary  granules,  nucleus-forms.  Nucleated  cells  are  commonly 
present  in  inconsiderable  number.  This  relates,  however,  more  espe- 
cially to  typhous  substance  in  the  bowel.  That  in  the  mesenteric  glands 
frequently  shows  nucleated  cells, — even  parent-cells  with  several  nuclei. 
Even  the  albuminous  constitution  of  the  typhous  substance,  and  the 
genuine  typhous  crasis  itself,  to  which  fibrinous  exudation  is  a  stranger, 
involve  an  analogy  with  medullary  carcinoma  and  its  crasis.  All  fibri- 
nous products  occurring  in  the  typhous  substance  itself,  or  along  with  it 
upon  the  same  textures — the  intestinal  mucous  membrane — or  in  any 
other  organ,  are  not  proper  to  the  true  typhous  process,  but  to  a  secon- 
dary croupous  crasis,  into  which  the  typhous  crasis  so  often  degenerates 
at  various  periods  of  its  progress. 

VILLOUS   CANCER. 

An  alien  growth,  whose  cancerous  nature  is  incontestably  proved, 
both  by  its  attendant  cachexia,  and  by  its  frequent  alliance  with  the 
cancers  before  discussed.  Owing  to  the  close  affinity  of  its  elementary 
structure  with  that  of  medullary  carcinoma,  we  place  it  next  in  array 
with,  or  as  a  variety  of,  the  latter ;  with  which,  moreover,  it  has  in  com- 
mon the  loose  consistency,  the  abundant  v^scularity,  and  the  proclivity, 
to  hemorrhage  and  to  inflammation. 

So  far  as  we  know,  it  occurs  solely  upon  membranes,  for  the  most 
part,  the  pituitous,  and  most  particularly  upon  that  of  the  urinary 
bladder,  as  so-called  villous  muco-membranous  tumor.  It  also,  although 
far  less  frequently,  affects  the  common  integuments  and  serous  mem- 
branes. 

At  the  outset,  it  appears  as  a  delicate,  cord-like  excrescence  of  vari- 
ous length,  which  arises  out  of  the  aforesaid  textures  with  a  seeming 
longitudinal  fibrillation,  diverging  at  its  free  extremity  into  branches  and 
twigs.  Hereupon,  if  not  before,  it  forms  into  delicately  membraned 
villi,  and  with  this  expansion  of  its  texture,  bulges  at  its  free  end  into  a 
club-like  or  cauliflower  shape.  This  section  of  the  excrescence  invaria- 
bly contains  a  whitish,  or  reddish  white,  encephaloid  sap.  At  this  point 
it  is  particularly  vascular,  and,  in  its  recent  state,  of  a  purple  tint. 

A  minute  inspection  shows  the  alien  growth  to  consist  of  a  fibro-mem- 
branous  texture,  densely  involuted  at  the  pedicle,  and  developed  at  the 
free  extremity  into  a  stroma  for  the  reception  of  the  imbedded  encepha- 
loid. This  stroma  is  a  delicate,  structureless  or  striated,  fine-fibred 
membrane,  studded  with  elementary  granules  and  nuclei,  whilst  the 
encephaloid  sap  consists  of  elementary  granules,  nuclei,  And  cells  of 
every  variety  of  form.  Such  excrescences  not  unfrequently  vegetate  in 
great  numbers,  either  scattered  or  densely  grouped,  upon  the  mucous 
membrane  of  the  bladder,  imparting  to  it  a  long-drawn,  villous  aspect, — 
a  condition  ascribed  by  Andral  to  a  preternatural  development  of  the 
muco-membranous  villi. 

It  is  very  common  for  them  to  vegetate  particularly  densely  on  a 
circumscribed  patch,  to  become  blended,  at  the  pedicle  and  at  the  ex- 
panded points,  into  a  diffuse,  roundish  head,  furnished  with  a  neck,  which, 
if  it  contains  much  of  the  encephaloid  juice,  presents  a  uniform,  pulpous 


EPITHELIAL    CANCER.  217 

consistency,  and  a  superficial  lobulation,  whilst,  in  the  opposite  case,  its 
periphery  is  villous. 

The  growth  often  bleeds  spontaneously,  and  its  excessive  vulnerability 
occasions,  upon  very  slight  injury,  exhausting  hemorrhage. 

From  the  above  description,  the  medullary,  cancerous  nature  of  the 
alien  growth  is  manifest,  particularly  its  analogy  with  that  encephaloid, 
medullary  carcinoma,  provided  with  a  stroma.  It  is  clearly  nothing 
more  than  medullary  carcinoma  with  predominant  stroma-formation. 

EPITHELIAL   GROWTHS,    EPITHELIAL    CANCER. 

These  growths  are  without  doubt  often  merely  local,  and  curable  by 
extirpation.  In  many  cases,  however,  notwithstanding  precisely  the 
same  morphological  and  chemical  relations,  they  accord  so  entirely  in  all 
their  manifestations  with  the  cancers,  that  we  classify  them  with  these 
as  a  further  variety  of  medullary  carcinoma,  to  which  in  their  lineaments, 
also,  they  approximate  the  most  nearly. 

Their  occurrence  we  believe  to  be  limited  to  the  mucous  membranes 
and  the  common  integuments.  We  have  seen  them  upon  the  mucous 
membrane  of  the  larynx  and  trachea ;  of  the  stomach,  the  rectum,  the 
urinary  bladder  ;  upon  and  in  the  common  integument,  and  in  the  subcu- 
taneous textures  of  the  lips  and  face ;  in  the  scrotum,  glans,  and  prepuce  ; 
in  the  external  labia  pudendi ;  upon  the  skin  of  the  lower  extremities. 
In  a  parenchyma  we  have  met  them  but  once,  namely,  in  the  liver, 
where  they  were  encysted  in  a  capsule  of  fibro-cellular  tissue. 

Upon  mucous  membranes  these  alien  growths  usually  appear  as  rather 
thickly  pedunculated,  roundish,  cauliflower-like,  or  warty,  leaf-like, 
stella-clavate,  whitish,  reddish-white,  purple,  vascularized,  sometimes 
tolerably  firm,  often  flabby,  very  vulnerable  tumors,  easily  rent  asunder 
by  compression.  Upon  the  common  integument  they  sometimes  form 
similar,  now  and  then  tolerably  voluminous,  tumors.  More  frequently, 
-however,  the  alien  growth  appears  as  a  diffuse  degeneration  of  the  skin, 
which  presents  a  warty,  foliated  surface,  overgrown  with  luxuriating 
papillae,  or  else,  under  different  structural  relations  of  the  new  growth,  a 
gland-like,  sore,  whitish-red,  or  red  patch,  which,  under  sloughing  and 
offthrowing  of  the  alien  growth,  degenerates  into  one  or  several  ridge- 
bound  ulcers. 

A  more  minute  examination  shows  these  out-growths  to  consist  alto- 
gether of  cells,  which  have  hitherto  seemed  to  us  perfectly  analogous, 
both  in  themselves  and  in  their  development,  with  the  epidermidal  or  the 
greater  epithelial  cells  of  the  tessellated  structure.  The  mature  cells  are 
often  of  colossal  size,  flattened,  mostly  rhomboidal,  furnished  with  one  or 
two  oval,  reddish,  or  yellowish-red  nuclei.  The  younger  cells  are 
smaller,  roundish,  spherical,  limpid,  or,  around  the  nucleus,  granulated 
in  the  figure  of  a  sharply  defined  areola ;  whilst  roundish,  pale-red  nuclei 
are  present  at  their  side.  The  older  cells  are  of  scale-like  flatness, — 
their  nuclei  indistinct,  or,  it  may  be,  completely  obliterated. 

In  ulterior  development  the  cell  does  not  surpass — 

(a.)  A  lengthening  in  one  direction,  with  transformation  to  a  rhomb 
or  to  a  riband-like  layer  terminating  at  both  ends  in  a  short  apex. 


218  EPITHELIAL    CANCER. 

(b.)  A  parent-cell,  within  which  occurs  a  second  generation  of  cells,  a 
development  indicative  of  an  alveolar  disposition  in  the  other  surrounding 
elements. 

These  elements  are  held  together  by  a  very  scanty,  imperceptible,  in- 
tercellular substance,  and  give  way  under  moderate  pressure,  or  without 
this,  under  the  influence  of  acetic  acid,  or  of  other  acids  which  serve  to 
dissolve  the  intercellular  substance. 

The  cells  themselves  manifest  towards  acetic  acid  relations  varying  with 
their  age,  the  older  ones  not  being  changed,  the  younger  ones  becoming 
more  transparent  and  gradually  dissolved  by  it,  whilst  the  nuclei  are 
brought  more  distinctly  into  relief.  When  rubbed  up  with  water  they 
impart  to  it  a  whitish  turbidness,  and  the  young  cells  lend  to  their  laxer 
bond-substance  an  encephaloid  aspect. 

The  secondary  arrangement  of  these  elements  is  very  remarkable.  It 
consists: 

(a.)  In  their  arraying  themselves  in  warty,  or  warty  layer-like 
growths. 

(b.)  In  their  arraying  themselves  in  cylindrical  or  facetted  fibres  or 
cylinders,  which,  gathered  together  into  fasciculi,  give  the  new  growth  a 
fibred  structure,  a  fibrous  torn  surface. 

(<?.)  In  alveolar  order.  Elongated  celjs  of  the  secondary  form  above 
specified,  course  around  circular  gaps  in  which  are  impacted  a  brood  of 
younger  nucleated  cells,  either  spherical,  or,  when  very  numerous, 
mutually  compressed  into  polygonal  shapes. 

In  the  larynx,  this  formation  constitutes  the  out-growths  denominated 
by  Albers  warty,  laryngeal  tumors;  many  lax,  succulent,  seemingly 
fibrous,  for  the  most  part  very  sensitive,  integumental,  and  subintegu- 
mental  warts,  a  large  proportion  of  cancers  of  the  lip,  scrotal  or  chim- 
ney-sweeper's cancer,  a  not  uncommon  condyloma-like  degeneration  of 
the  glans  penis,  cancer  of  the  external  sexual  organs  in  the  female,  and 
especially  of  the  external  labia.  Many  of  these,  more  particularly 
cancers  of  the  lips,  have  a  seeming  glandular  texture  determined  by  the 
alveolar  type.  From  the  common  integument  they  assail  subcutaneous 
textures  without  distinction, — even  bone  ;  from  mucous  membranes,  the 
submucous  textures  :  at  the  larynx,  the  arytenoid  cartilages  so  commonly 
that  one  is  induced  to  believe  that  the  alien  substance  may  in  some  cases 
originate  with  these. 

Epidermidal  cancer  ulcerates,  in  the  sequel  of  inflammation,  in  a  form 
identical  to  all  appearance  with  that  of  the  most  exquisite  cancer.  The 
base  of  the  ulcer  is  invested  with  a  yellowish-white,  or  a  white,  cream- 
like  exudate,  consisting  mostly  of  lustrous,  reddish  nuclei.  Lastly,  to 
this  alien  growth  is  to  be  reckoned,  without  doubt,  an  ulcer  developed 
out  of  a  wart-like,  transparent,  hardish  protuberance,  in  form  thoroughly 
identical  with  ulcerating  cancer,  and  not  unfrequently  seen  to  attack 
aged  persons  in  the  face.  The  base  and  edges  of  this  ulcer  consist  of 
round,  lustrous,  reddish  nuclei  in  an  amorphous  bond-mass,  and  the 
white,  creamy  exudate  investing  the  ulcer  reveals  the  same  composition. 
It  represents  embryonic  stages  of  epithelial  cancer.  Certain  epidermidal 
cancers  of  the  lip  are  similarly  constituted. 


CARCINOMA    FASCICULATUM.  219 

CARCINOMA  FASCICULATUM. 

(Johannes  Mutter.) 

Formerly  termed,  also  by  Johannes  Muller,  carcinoma  hyalinum,  be- 
cause of  its  jelly-like  transparency.  An  alien  growth,  according  to  our 
observation,  of  very  rare  occurrence,  which  we  have  met  with  but  twice  ; 
once  in  the  mammary  gland,  and  once  again  in  most  of  the  internal 
organs  simultaneously,  as  almost  general  cancer. 

The  first  case,  which  we  had  better  means  of  examining,  relates  to  a 
growth  of  considerable  size,  nearly  that  of  an  infant's  head,  of  uneven, 
clavate  surface,  of  a  pale-yellow  color,  of  jelly-like  transparency,  and 
withal,  of  notable  compactness.  It  consisted  of  an  aggregate  of  tubera, 
which  resolved  themselves  into  a  certain  number  of  cones,  flat-sided  from 
reciprocal  compression,  with  their  notched  and  ruffled  bases  directed 
outwardly,  and  their  apices  pointing  to  within,  so  that  the  apices  of  all 
the  cones  constituting  a  tuber  converged  to  a  common  centre.  The  in- 
tersection between  the  individual  tubers  was  occupied  by  a  somewhat 
more  substantial, — that  between  the  cones  by  a  more  delicate, — membra- 
nous, whitish,  areolar  tissue-like  bond-mass.  Bloodvessels,  so  far  as  they 
could  be  traced  in  a  not  highly  injected  condition,  ran  in  a  direction 
parallel  to  the  cones.  A  microscopic  examination  showed  the  paren- 
chyma to  consist  of  somewhat  long-drawn,  delicate,  hyaline  fibres,  be- 
tween which,  in  an  almost  limpid  juice,  lay  imbedded  elementary  granules, 
nuclei,  and  a  few  scattered,  elongated  cells. 

Without  conforming  to  Miiller's  description  in  what  concerns  the 
presence  of  embryonic  elements,  this  growth  accords  with  it,  neverthe- 
less, so  fully  in  other  respects,  as  to  justify  us  in  pronouncing  it  to  be  a 
true  specimen  of  carcinoma  fasciculatum  or  hyalinum. 

In  the  other  case,  the  secondary  arrangement  of  the  large  conical 
fasciculi  was  less  orderly,  and,  throughout,  that  before  depicted,  the  con- 
sistence more  lax,  the  transparency  the  same.  This  latter,  according 
to  Muller,  is  inconstant,  and  it  was  for  this  reason  that  he  afterwards 
substituted  for  carcinoma  hyalinum,  the  appellation  of  carcinoma  fasci- 
culatum. 

The  specimens  examined  by  Johannes  Muller  were  of  a  consistency- 
analogous  to  that  of  encephaloid.  He  admits,  however,  that  in  this 
respect  variations  may  occur,  and  that  firmer  specimens  of  carcinoma 
fasciculatum  are  probably  to  be  met  with. 

CYSTO-CARCINOMA. 

Cysto-carcinoma  specially  affects  certain  organs,  as  the  ovary,  the 
mammary  gland,  the  testicles,  bones.  It  is  mostly  a  growth  of  considera- 
ble magnitude,  and  commonly  concurrent  with  cancer  in  other  organs. 
[See  Cyst  and  Alveolus. ~\ 

APPENDIX. 

[A  careful  examination  instituted  by  the  author  in  sundry  cancerous 
tumors,  more  especially  of  the  medullary  character,  have  led  to  interest- 
ing results  illustrative  of  the  development  and  the  microscopic  structure 


220  CANCER. 

of  these  malignant  growths.  Without  dragging  the  reader  through  the 
details  of  cases  which  seem  only  to  represent  so  many  stages  of  develop- 
ment,— so  many  links  in  the  chain  of  evidence, — we  shall  endeavor  to 
sum  up  the  results  in  as  few  words  as  possible. 

Under  a  magnifying  power  of  90  diameters,  the  substance  of  fungus 
hsematodes  exhibits  a  stroma  consisting  of  two  distinct  webs,  which 
appear  to  interlace  each  other  in  all  directions.  Of  these,  the  one  has 
the  semblance  of  a  transparent  trelliswork,  studded  with  caudate  cells, 
elongate  nuclei,  and  long-drawn  fibres,  all  lying  parallel  to  the  longitu- 
dinal axis  of  the  stroma.  The  gaps  or  meshes  of  this  stroma  are  inter- 
laced or  enwreathed  with  what  at  first  appears  like  a  continuous  garland 
of  leaves,  but  on  a  closer  inspection  is  seen  to  terminate  in  bulb-shaped 
extremities.  Further  examination  shows  this  wreath-like  tissue,  which 
at  first  seemed  opaque  and  granular,  to  be  studded  with  crowds  of  minute 
nucleated  cells,  which,  under  a  magnifying  power  of  400,  are  distinctly 
set  forth  as  round  or  oval  cells,  many,  although  not  all,  containing  one  or 
several  nuclei,  others  engaged  in  the  act  of  elongation,  others  again  in 
progress  of  dissilience. 

In  preparations  representing  a  further  stage  of  development,  the  wreath- 
like  tissue  presents  certain  patches  much  less  opaque,  its  cells  for  the 
most  part  elongated,  and  many  of  its  nuclei  drawn  out  into  disconnected 
fibres.  There  is  good  reason  for  regarding  this  portion  as  in  a  state  of 
transition  from  the  wreath-like  tissue  to  the  supporting  stroma  first  de- 
scribed. In  the  next,  and  last,  phase  of  development,  is  represented  the 
same  trelliswork,  no  longer  thinly  fibred  and  semitransparent,  but 
rendered  opaque  by  connected  and  dense  longitudinal  fibrillation.  These 
fibred  trellises  are  here  distinctly  seen  to  be  enveloped  in  a  hyaline 
structureless  membrane,  not  closely  fitting,  but  loose  and  projecting  on 
all  sides  into  the  fenestrate  gaps  in  conical  and  bulb-like  excrescences. 
It  is  remarkable,  that  from  the  first  period  of  their  fibrillation,  these 
trellis  branches  are  observed  to  constitute  hollow  cylinders.  This  may 
be  owing  either  to  a  single  cell-layer  being  alone  present  within  the 
excrescences,  or  else  to  the  fact,  that  of  a  cell-mass  with  which  the 
excrescence  is  replete,  only  one  layer  becomes  fibrillated  and  the  rest 
absorbed. 

Although  the  proof  is  difficult,  there  is  good  reason  for  believing  that 
the  hollow  cylinders  referred  to  are  filled  with  the  same  cancerous  sub- 
stance that  furnishes  the  outer  material  for  the  excrescences. 

Certain  external  features,  analogous  with  the  above,  induced  Roki- 
tansky  to  submit  to  a  close  investigation  those  adventitious  membranes 
upon  serous  tunics,  which  present,  with  a  honeycombed  aspect,  a  free- 
villous  surface.  The  process  of  development  resembles  that  of  the  cancerous 
growths,  only  that  in  these  pseudo-membranous  formations  the  wreath- 
like  tissue  more  frequently  occurs  in  layers  parallel  to  the  gaps  or  open 
spaces  of  the  primitive  fenestrate  layer,  or  in  superimposed  order  and 
sometimes  in  thick  masses,  tufted  with  many  prominent,  short-necked, 
terminal  bulbs.  It  will  be  seen,  from  Rokitansky's  great  "  Essay  on 
Diseases  of  the  Arteries,"  that  the  intra-arterial,  superimposed  layers  of 
coagula  present  very  nearly  the  same  structural  development.  (See 
"Die  Entwickelung  der  Krebsgeriiste,"  from  the  " Sitzungsberichtie  der 


CANCER.  221 

math-naturw.  Classe  der  Kais.  Akademie  der  Wissenschaften,"  Marz, 
1852.) 

In  a  subsequent  essay  on  villous  cancer  (April,  1852),  and  a  third  on 
colloid  cancer  (July,  1852),  Rokitansky  has  made  it  apparent  that,  with 
certain  modifications  contingent  upon  the  general  conformation  of  the 
tumors  and  upon  the  nature  of  their  contents,  the  same  general  relations 
of  structure  pertain  to  these  cancers  likewise. 

In  the  colloid  cancer  there  is  a  similar  formation  of  a  multilocular 
stroma,  which,  however,  often  assumes  rather  a  membranous  fabric.  This 
honeycombed  structure  contains  within  its  cancelli,  the  colloid  or  gelati- 
nous mass,  which  is  for  the  most  part  connected  together,  so  as  in  a 
manner  to  interlace  with  the  said  stroma,  and  only  here  and  there  to 
occur  in  shut  sacs  or  cystoids,  formed  through  the  blending  of  the  mem- 
branous framework.  Rokitansky  has  obtained  evidence,  that  from  the 
walls  of  these  shut  spaces,  bulbous  forms  arise,  and  that  the  colloid 
globules  are  formed  within  these,  as  the  product  of  a  hyaline  blastema 
with  which  they  are  more  or  less  replete.  He  seems  to  infer  that  the 
fibro-membranous  stroma  is  itself  but  a  development  out  of  primitive 
hollow  bulbs. 

There  is  in  this  theory  respecting  the  aforesaid  formation  of  the 
encysted  masses  of  colloid,  a  general  withdrawal  by  the  author  of  one 
opinion  expressed  in  the  section  on  cysts,  namely,  that  in  these  new 
growths  the  cyst  is  invariably  developed  out  of  the  structureless  vesicle. 
The  term  cystoid  would  therefore  be  peculiarly  applicable  to  the  mem- 
branaceous  cavities  found  in  colloid  cancer,  as  distinguishing  them  from 
genuine  cysts. 

Villous  Cancer. — In  all  but  its  external  form,  this  cancer  approaches 
the  nearest  to  medullary  carcinoma.  A  very  important  part  is  here 
assigned  to  the  dendritic  excrescences,  into  which  the  primitive  hollow 
bulbs,  often  springing  from  a  densely  reticulate  germ,  speedily  resolve 
themselves ;  the  first  shoots  pushing  forth  from  their  terminal  bulbs 
secondary  offshoots  in  the  shape  of  slender  villi,  which  themselves  expand 
into  bulbs,  and  throw  out  more  of  these  embryonic  excrescences  from 
their  termination,  so  as  to  constitute  by  degrees  a  more  or  less  extensive 
cauliflower-  or  coral-shaped  tumor.  In  other  cases,  a  single  stem  arises 
out  of  a  nucleus  as  big,  it  may  be,  as  a  bean,  and  this  stem  branches  out 
into  dendritic  vegetations  of  the  character  above  described. 

Most  of  these  excrescences  end  in  csecal  sacs,  some  of  which  may  con- 
tain a  structureless,  or  a  concentrically  stratified  cyst. 

These  excrescences  are  often  transparent,  containing  in  their  cavity 
only  a  clear  fluid,  whilst,  externally,  they  grow  up,  as  it  were,  into  a 
more  or  less  tenacious  plastic  mass,  consisting  of  the  same  elements  that 
compose  the  sap  of  medullary  cancer.  In  other  instances,  they  include 
a  fibrous  texture,  within  which  reside  elements  similar  to  those  that  cling 
to  them  externally.  A  remarkable  circumstance  connected  with  these 
excrescences  is  the  peculiar  way  in  which  they  are  vascularized.  Both 
the  stem  of  the  tumor  and  all  its  individual  excrescences  are  furnished 
with  an  ascending  and  descending  bloodvessel,  which  pursues  its  course 
under  the  formation  of  frequent  loops.  These  bloodvessels  consist  mostly 


222  CANCER. 

of  the  primitive  hyaline  bloodvessel  membrane,  marked  with  oblong 
nuclei,  sometimes  also  with  a  row  of  transverse  oval  nuclei.  There  may 
possibly  be  a  further  layer  of  connective  tissue  fibrils.  A  few  of  the 
excrescences  have  but  a  single  ascending  bloodvessel,  terminating  in  a 
sort  of  bulb. 

In  rare  instances,  a  nest  of  apparent  excrescences  displays  open  ter- 
minations fringed  with  villi,  and  filled  with  the  semifluid  materials  of 
medullary  cancer.  Rokitansky  is,  however,  of  opinion,  that  these  are 
not  true  excrescences,  but  rather  lengthy  developments  of  the  fibro- 
cellular  texture  which  constitutes  the  base  of  the  tumor ;  and  he  believes 
these  hollow  cylinders,  which  seem  rather  to  resemble  the  honeycomb  of 
the  wasp,  to  become  filled,  not  by  endogenous  secretion,  but  by  suction 
of  the  external  medullary  fluid. 

Seat  of  Villous  Cancer. — Its  seat  is  more  especially  upon  mucous 
membranes,  and  most  of  all  that  of  the  male  urinary  bladder,  near  the 
opening  of  either  ureter;  next  to  this,  the  mucous  membrane  of  the 
stomach,  and  in  particular  the  pyloric  portion.  It  has  been  observed 
suspended  by  a  pedicle  from  the  internal  membrane  of  the  rectum,  and 
even  from  that  of  the  gall-bladder. 

Secondly,  it  is  very  apt  to  grow  extensively  from  the  internal  wall  of 
ovarian  cysto-carcinoma,  where  it  is  recpgnized  as  villous  cancer,  from 
its  copious  accompaniment  of  medullary  sap.  In  these  cases,  it  is  often 
concurrent  with  cancerous  infiltration  of  the  lymphatic  glands,  about 
the  lumbar  vertebrae,  and  with  peritoneal  cancer, — representing  villous 
cancer  upon  a  serous  membrane. 

It  has  been  observed  upon  the  dura  mater,  occasionally  upon  the 
general  integument  (Rokitansky  refers  to  two  such  cases),  and  even  in 
bone, — reckoning  for  villous  cancer  those  cases  in  which  a  bony  skeleton 
is  found  in  the  shape  of  the  wasp's  honeycomb  structure  before  described. 

Lastly,  it  occurs  in  parenchymata,  in  the  uterus,  for  example ;  and, 
as  cancer  melanodes,  in  the  liver  and  in  the  brain. 

It  occurs  both  as  a  single  tumor,  and  also  concurrently  with  cancer 
of  various  kinds  in  other  organs, — occasionally  germinating  out  of  those 
broad-based,  fungus-like  gelatinous  cancer-masses  that  occur  upon  the 
inner  surface  of  the  stomach. 

"  The  vascularity  of  villous  cancer  determines  a  predominant  feature 
in  its  course,  whether  upon  membranous  surfaces,  in  the  interior  of 
cysts,  or  in  parenchymata,  namely,  the  frequent  hemorrhage  which  so 
greatly  hastens  the  general  wasting  and  the  fatal  issue.  Frequent  and 
excessive  hemorrhage  from  the  urethra  in  males,  from  the  vagina  in 
females,  furnishes  strong  suspicion  of  villous  cancer  affecting  respec- 
tively the  bladder  or  the  uterus,  whilst  a  microscopic  examination  of  the 
blood  effused  will  often  bring  to  light  shreds  or  fragments  of  the  cancer- 
ous mass." 

The  same  vascularity  often  causes  a  fleshy  coloration  of  the  tumor. 

It  is  evident  from  the  foregoing,  that  villous  cancer  is,  to  all  intents 
and  purposes,  a  malignant  new  growth :  and  not,  as  Andral  and  Louis 
have  affirmed,  an  anomalous  development  of  muco-membranous  villi ; 
nor,  as  others  have  more  recently  suggested,  a  tumor  arising  out  of  the 
hypertrophy  of  a  pre-existent  papilla.] 


TUBERCLE.  223 


TUBERCLE. — TUBERCULOSIS. 

The  collective  term  "  tubercle"  is  made  to  embrace  sundry  forma- 
tions, which  have  nothing  in  common  beyond  their  outward  form. 

Still,  after  having  well  sifted  this  side  of  the  question,  we  shall  our- 
selves feel  bound  to  comprise  under  "tubercle,"  formations  in  external 
appearance  quite  dissimilar  to  what  is  commonly  called  tubercle,  never- 
theless essentially  identical  with  it ;  for  instance,  the  primitively  yellow, 
fibrino-croupous  tubercle. 

If  we  except  the  rare  instances  in  which  it  represents  an  endogenous 
deposition  within  the  circulating  system,  tubercle  is  in  the  broadest  sense 
an  exudate — an  exudate  of  solidified  protein  substances  (fibrin,  albu- 
men), which  as  blastema  persists  at  the  lowest  grade  of  development; 
that  is  to  say,  in  the  primitive  crude  condition  determined  by  its  con- 
solidation. It  thus  occupies  the  point  of  transition  to  the  non-organized 
new  growths. 

This  last  attribute  is  essential  and  indispensable,  imparting  to  solid 
blastema  the  impress  of  tubercle.  It  is  so  important,  that  every  blas- 
tema, however  much  its  characters  may  assimilate  to  tubercle  in  other 
respects,  loses  the  distinctive  mark  the  moment  it  enters  upon  a  trans- 
formation of  texture. 

This  exudate  (in  its  broadest  sense)  is  for  the  most  part  distinguished 
by  the  tubercle-form ;  that  is,  by  its  appearance  as  scattered  or  col- 
lected nodules,  or  where  more  copiously  produced,  by  its  deposition  in 
granulations  and  stellate  masses.  It  is  hereby  cognizable  at  the  first 
glance.  Still  this  is  open  to  exceptions. 

Gelatinous  and  fibrous  cancer  appear  now  and  then  in  a  tubercle-like 
form ;  that  is,  in  the  form  of  little  discrete  nodules  or  stellate  bodies ; 
and,  upon  serous  membranes,  the  peritoneum,  for  example,  there  occur 
granular  exudates  of  fibroid  and  areolar  tissues.  These  are  distin- 
guishable from  tubercle  by  their  texture. 

But,  again,  even  tubercle  itself  occurs  in  extensive,  irregular  masses. 
There  are  inflammatory  products  endowed  with  an  indwelling  tuber- 
culous character,  although  manifesting  a  total  absence  of  the  external 
habitudes  of  tubercle. 

Tubercle  has  therefore  sometimes  a  local,  but  far  more  frequently  a 
general  import  and  significance.  It  is  invariably  so  closely  linked  with 
dyscrasial  processes,  that,  for  a  profitable  consideration  of  tubercle,  an 
incessant  retrospect  to  the  dyscrasial  relations  is  imperatively  demanded. 

Nevertheless,  the  basis  and  starting-point  for  an  anatomical  inquiry 
concerning  tubercle  itself,  must  in  our  opinion  still  be  the  aforesaid 
fixed  blastema  abiding  at  its  primitive  stage  of  crudity. 

In  this  sense  tubercle  offers  sundry  distinctions,  some  obvious  and 
essential,  others  less  marked.  They  relate  to  its  color  and  lustre,  its 
transparence,  its  consistence,  its  elementary  fabric,  chemical  compo- 
sition, &c.  These  are  characters  referable  to  more  or  less  manifest 
special  crasial  relations — modifications  of  a  fundamental  tubercle-crasis. 
They  determine  several,  and  some  of  them  essential,  forms  of  tubercle, 


224  TUBERCLE. 

| 

which  we  shall  proceed  at  once  to  portray,  selecting  for  our  basis  the 
purest  possible  forms. 

(a.)  Simple  fibrinous  tubercle  appears  as  scattered  or  stellate  conglo- 
merations of  granules  of  about  the  size  of  millet-seeds.  It  presents, 
moreover,  as  the  product  of  inflammation  upon  serous  membranes, 
smooth  pseudo-membranous  exudates,  as  we  often  find  exemplified  upon 
the  pleura  of  lungs  involved  in  florid  phthisis. 

In  the  first-known  form  this  tubercle  represents  the  gray  semi-trans- 
parent granulations  of  Laennec. 

The  investigations  and  theories  hitherto  instituted  relate  almost 
exclusively  to  this  tubercle,  from  which  all  other  tubercle-formations 
have  been  derived  as  from  a  stereotype  basis. 

The  question  of  old — What  is  tubercle  ?  must  at  this  day  be  changed 
into — What  is  this  particular  tubercle  ? 

In  its  early  stage,  at  which  acutely  generated  tubercle  is  often 
enough  to  be  obtained  in  the  human  subject,  it  appears  in  the  form  of 
the  aforesaid  granulation, — to  the  naked  eye  a  roundish,  resistant,  solid 
nodule,  of  about  the  size  of  a  millet-seed.  Not  unfrequently,  however, 
we  encounter  amongst  them  tubercles  somewhat  smaller,  and  repre- 
senting a  less  firm,  a  softer,  at  the  same  time  more  transparent,  almost 
vesicle-like  granule. 

Nevertheless,  however  much  tubercle  may  at  a  first  glance  wear  a 
vesicular  appearance,  it  invariably  originates  as  a  solid  corpuscle ;  and 
the  results  of  a  careful  analysis  of  this  substance,  as  well  as  its  very 
nature  and  import,  serve  to  corroborate  this  fact. 

Minutely  examined,  it  only  seemingly  represents  a  spherical  body. 
Under  a  moderate  magnifying  power, — nay  even  on  a  narrow  inspection 
with  the  naked  eye,  it  is  seen  at  its  circumference  to  branch  out  more 
or  less.  With  the  textures  it  is  only  in  so  far  connected  as  to  lodge 
betwixt  their  elementary  parts,  to  take  up  some  of  these  into  its  sub- 
stance, and — what  is  especially  discoverable  in  tubercle  upon  serous 
membranes, — to  adhere  to  them  by  dint  of  an  indwelling  tenacious 
property.  It  represents  a  tolerably  homogeneous — now  toughish,  gritty, 
fibro-granular,  fragile,  now  softish,  uniformly  compressible — substance, 
in  various  shades  and  modifications,  of  a  pearly  gray  color. 

Under  the  microscope  it  reveals  the  following  elementary  compo- 
sition : 

It  consists  mainly  of  a  more  or  less  pellucid  base  (blastema),  wrhich 
affords  a  sort  of  binding  medium  for  certain  form  elements.  Its  compo- 
nents therefore  are — 

1.  The  said  basement-mass, — for  the  most  part  a  fibro-glebous,  gray, 
fixed  blastema,  rendered  turgescent  and  transparent  by  acetic  acid. 

2.  Certain  embryonic  form-elements,  namely : 
(a.)  Elementary  granules  of  various  magnitude. 

(b.)  Nucleus  formations,  both  black-contoured,  lustrous,  spherical, 
even  oblong  nuclei, — and  more  delicate,  dull,  granulated  nuclei,  under 
various  phases. 

(c.)  Nucleated  cells;  commonly  in  such  small  numbers  as  to  tempt 
one  to  doubt  their  occurrence  altogether.  Nuclei  and  cells  are  often  to 


TUBERCLE.  225 

a  great  extent  misshapen,  disorderly,  jagged,  angular,  bulging,  dumb- 
bell-shaped, rudirnental,  stunted. 

Along  with  this,  the  tubercle  is  wont  to  include  various  elements 
appertaining  to  the  textures  in  which  it  nestles.  The  tubercle  purest  in 
this  respect  is  that  upon  serous  membranes,  which,  therefore,  like  many 
other  new  growths  upon  serous  membranes,  is  the  best  adapted  for  ex- 
amination. Nay,  tubercle  will  even  take  up  and  incorporate  compound 
textural  constituents,  and  in  particular  bloodvessels.  The  question  here 
suggested  as  to  tubercle-containing  vessels  of  its  own  will  be  discussed 
hereafter. 

The  metamorphosis  which  this  tubercle  undergoes,  is  limited  to  deca- 
dence. After  abiding  in  the  primitive,  crude  condition  before  described 
it  becomes  transformed,  with  the  loss  of  its  moisture, — with  condensation 
— to  a  hard  nodule,  and  shrivels,  into  a  tough,  amorphous  or  indistinctly 
fibrous,  horn-like  mass, — in  a  word,  cornifies.  This  determines  a  com- 
plete wasting  and  death  of  the  tubercle,  subversive  of  all  further  change. 
Occasionally  this  process  is  associated  with  bony  deposition,  the  tubercle 
becoming  a  partly  ossified  nodule. 

This  tubercle  does  not  undergo  any  other  metamorphosis  indepen- 
dently. Every  other  change  suffered  by  it  is  based  upon  a  combination 
of  its  blastema  with  another,  and  its  softening  in  particular,  upon  a  com- 
bination with  the  ensuing  tubercle,  namely,  the  fibrino-croupous.  This 
softening  process  plays  so  momentous  a  part  in  the  doctrine  of  tubercle, 
that  we  deem  it  right  to  declare  emphatically  our  dissent  from  the 
opinion  that  gray  tubercle,  the  gray  tuberculous  granulation  of  Laennec, 
softens. 

Fibrino-Croupous  Tubercle  appears  in  the  shape  of  roundish  nodules, 
as  also,  and  that  very  frequently,  of  irregular,  gibbous,  branched  masses 
of  considerable  diameter,  or,  upon  free  surfaces  as  gibbo-stellate  layers 
of  various  thickness.  The  nodules  in  size  often  equal  the  gray  tubercle 
granulations,  still  oftener  do  they  equal  hemp-seed  or  peas.  Usually, 
every  variety  of  size  coexists.  The  substance  of  this  tubercle  is,  as  we 
may  here  once  for  all  remark, — opaque  from  the  very  first,  now  resplen- 
dent, in  various  degrees,  yellow,  of  fibrous  or  of  granular  fracture,  firmly 
elastic,  or  friable,  of  a  lardaceous,  curd-like  aspect.  We  distinguish  it 
from  the  gray  tubercle  by  the  designation  of  yellow  tubercle.  It  most 
probably  constitues  the  pyin-holding  tubercle. 

The  microscopic  examination  of  this  tubercle  shows,  as  in  the  case  of 
the  foregoing  one,  a  fixed  base,  and  the  aforesaid  form-elements.  The 
former  is  a  fibro-glebous,  or  else  an  amorphous,  opaque  blastema.  "\Yith 
respect  to  the  latter  much  variety  obtains.  The  number  of  cells,  of 
nuclei,  especially  of  the  dull,  granulated  nuclei,  of  the  elementary 
granules,  and  especially  the  quantity  of  the  finest  point-molecule  pre- 
dominate. 

The  metamorphosis  proper  to  this  tubercle  is  softening,  and  again 
cretefaction. 

1.  The  first,  namely  softening,  also  termed  suppuration,  consists  in 
this :  after  the  tubercle  has  tarried  for  a  certain  time  in  the  above- 
described  condition  of  crudity,  it  loosens  up, — for  the  most  part  with 
considerable  increase  of  volume,  readily  breaks  asunder  through  compres- 

VOL.  I.  15 


226  TUBERCLE. 

sion,  moistens.  Hereupon  it  changes  into  a  yellowish,  glutinous,  fatty, 
tenacious  substance,  like  melted  cheese,  and  eventually  liquefies  to  a  thin, 
whey-like  fluid  of  acid  reaction,  wherein  flocculent  and  fragmentary 
particles,  the  remnants  of  tubercle  imperfectly  broken  up,  float  as 
tubercle-pus. 

In  the  larger  tubercle  masses  there  is  often  observable,  during  the 
said  process,  a  cleft  formation  on  a  large  scale ;  or,  where  the  tubercle 
is  spread  out  in  a  layer,  a  fissuring  of  this  latter. 

With  regard  to  the  elementary  character  of  the  tubercle  at  this  stage, 
we  would  observe : 

The  softening  consists  in  a  liquefaction  and  breaking  up  of  the  solidi- 
fied base  of  the  tubercle  to  a  fluid  loaded  with  point-molecule.  This 
transformation  results  in  a  separation  or  isolation  of  the  form-elements 
of  the  tubercle,  which  at  the  same  time  undergo  within  the  fluid  a  more 
or  less  marked  change.  Thus,  the  cells  become  turgescent,  corroded, 
dissolved ;  the  nuclei  shrivelled  and  misshapen,  irregularly  angular, 
pouched,  &c.  At  length  free  fat  becomes  developed  in  the  softened 
tubercle. 

Hence  the  liquefied  tubercle  consists  : 

(a.)  Of  a  fluid  with  point-molecule. 

(b.)  Of  the  isolated  nuclei  and  cells  changed  in  the  manner  just  now 
specified. 

(<?.)  Of  free  fat  in  the  shape  of  elementary  granules  and  larger  scat- 
tered globules. 

The  softening  determines  the  malignancy  of  tubercle,  leading  as  we 
shall  presently  see  to  ulcerous  destruction  of  the  textures, — tuberculous 
phthisis. 

2.  The  other  metamorphosis  of  this  tubercle  is  cretef action.  It  never 
affects  the  tubercle  blastema  in  its  primitive  condition,  but  only  in  its 
liquefying  or  liquefied  state. 

During  the  softening  process,  or  after  its  completion,  the  tubercle 
takes  up  lime-salts  and  fats,  in  the  shape  of  free,  discrete,  or  aggregated 
elementary  molecule,  or  else  in  granule-cells  in  the  form  of  big  drops 
and  of  cholesterine  crystals.  In  this  act  the  softened  tubercle  is  pro- 
gressively thickened  into  a  moist,  unctuous  chalk-pap,  and  eventually 
converted  into  a  concrete  mortar. 

Let  us  now  attempt  to  institute  an  inquiry  respecting  the  nature  of 
tubercle,  in  its  two  cardinal  forms,  as  just  delineated  ;  whereupon  we 
will  proceed  to  discuss  its  varieties,  its  metamorphosis,  its  local  process 
of  deposition,  its  seat,  and,  lastly,  its  relation  to  the  blood-crasis. 

In  the  first  place,  the  ground-work  of  rapidly  solidifying  tubercle 
blastema  is,  without  the  least  doubt,  fibrin.  Again,  in  the  two  cardinal 
forms  of  tubercle,  it  is  easy  to  recognize  the  two  principal  forms  of 
fibrin,  the  simple  and  the  croupous  (see  Fibrin).  Why  the  former,  which 
we  have  elsewhere  denominated  plastic,  enters  into  no  textural  conver- 
sion, why  the  latter  fails  to  undergo  that  prompt  liquefaction  proper  to 
the  croupous  exudates,  are  questions  which  we  shall  endeavor  to  reply  to 
in  a  more  appropriate  place. 

With  reference  to  the  varieties  of  these  cardinal  forms,  we  would 
observe — 


TUBERCLE.  227 

(a.)  Of  croupous  tubercle  there  occur  several  varieties,  together  re- 
minding us  of  croupous  fibrin  and  its  resulting  exudates.  They  are 
determined  by  opacity,  coloration,  consistency,  tendency  to  liquefaction, 
by  the  corrosive  property  of  their  ichor,  the  proportion  of  their  form- 
elements,  of  their  point-molecule,  and  by  the  character  and  import  of 
their  nucleus  and  cell-formations. 

(b.)  Like  blastema  in  general,  tubercle  blastema  is  especially  unwont 
to  exude  pure.  The  combination  of  the  two  cardinal  tubercle-blastemata 
in  different  proportions,  and  their  manifold  grades  of  co-ordination  and  of 
blending ;  again,  the  union  of  varieties  of  croupous  tubercle  with  each 
other,  and  with  organizable  blastema  (fibrin),  break  up  tubercle  into 
countless  varieties. 

In  like  manner,  the  gray  tubercle  granulation  presents  many  varia- 
tions in  respect  to  transparency,  coloration,  &c.,  the  greenish  shade,  for 
example. 

A  peculiar  variety  is  the  pigmental  tubercle,  for  the  most  part  hemor- 
rhagic,  as  to  its  origin. 

As  metamorphoses  of  tubercle,  we  have  already  been  made  familiar 
with  its  decadence  or  obsolescence,  its  softening,  and  its  cretefaction. 
The  first  is  proper  to  the  simply  fibrinous,  the  last  two  to  the  fibrino- 
croupous  tubercle.  These  metamorphoses  affect  tubercle  in  common  with 
consolidated  blastemata  of  a  certain  constitution,  whether  they  occur  as 
exudates  (even  as  extravasate1)  external  to  the  vascular  system,  or  as 
endogenous  coagula  within  the  bloodvessels.  Their  cause  is  primitively 
inherent  in  the  tubercle,  conformably  with  our  view  respecting  the  pri- 
mordial properties  of  blastemata. 

1.  The  obsolescence  of  tubercle,  hitherto  disregarded,  is  cosignificant 
with  its  cornification.     It  implies  wasting,  extinction  of  the  tubercle. 

2.  Softening  of  tubercle,  a  metamorphosis  which  it  enters  upon  with- 
out distinction  of  volume — resolves  itself  into  that  elementary  phenome- 
non, the  breaking  down  of  solidified  protein  substances,  and  especially  of 
solidified  fibrin, — a  phenomenon  pertaining  to  this  substance  only  in  its 
determinate   croupous  constitution.     It   is   proper   to   fibrino-croupous 
tubercle  alone,  and  is  determined  by  a  conversion  of  the  chemical  com- 
ponents arising  out  of  an  interchange  of  the  elements. 

G-enuine  gray  tubercle-granulation  never  softens.  A  combination  of 
its  blastema  with  that  of  fibrino-croupous  tubercle  alone  capacitates  it  for 
softening.  It  was,  indeed,  formerly  taught,  that  gray  tubercle-granula- 
tion lost  its  gloss,  its  transparency,  became  opaque,  of  a  yellowish-white 
or  yellow,  and  ultimately  softened  and  deliquesced.  The  error  probably 
arose  from  a  readiness,  in  the  frequent  cases  where  the  two  forms  of 
tubercle  are  concurrent  and  even  now  and  then  mingle  together  into  a 
kind  of  transition  link  from  the  one  to  the  other,  to  take  for  granted 
that  they  represented  in  reality  two  different  stages  of  development. 

We  have,  however,  a  second  error  to  rectify  besides.  Long  ago  the 
softening  of  tubercle  was  described  as  a  development, — a  progressive 
metamorphosis, — but  in  general  and  not  very  lucid  terms.  Present 

1  The  term  "  extravasate"  is  used  by  German  pathologists  in  a  restricted  sense  only,  namely, 
to  signify  the  effusion  of  substantive  blood,  with  blood-globules,  into  surrounding  textures, — 
in  other  words,  internal  hemorrhage  from  ruptured  or  wounded  bloodvessels. 


228  TUBERCLE. 

pathology,  whilst  adopting  the  older  views  concerning  the  softening  of 
tubercle,  is  influenced  by  the  microscopic  discovery  of  an  incomparably 
greater  number  of  nuclei,  and  especially  of  cells,  in  softened  than  in 
gray  tubercle.  They  are  looked  upon  as  new  formations  out  of  the 
liquefied  tubercle  blastema. 

We  cannot  participate  in  this  view.  Those  elements  are  not  recently 
generated  out  of  the  liquefied  blastema,  but  proper  to  the  tubercle  from 
the  commencement,  and  isolated  by  the  softening  process.  That  they 
are  more  numerous  in  softened  tubercle  than  in  the  gray,  is  explained 
by  the  fact,  that  only  that  tubercle  softens  which  originally  holds  them 
in  abundance,  namely,  the  yellow  (croupous)  form. 

In  point  of  fact,  no  fluid  is  less  adapted  to  furnish  the  blastema  for 
new  growth  than  the  so-called  pus  of  tubercle.  The  softening  of  tubercle 
takes  place  sometimes  early,  sometimes  late, — rapidly,  or  by  slow  de- 
grees. All  this  depends  upon  certain  peculiarities  in  the  character  of 
the  (croupous)  tubercle.  In  this  process  it  is  worthy  of  note,  that  in 
tubercle  masses  deposited  all  at  once,  the  softening  proceeds  from  the 
central  part ;  whereas,  in  aggregate  masses  thrown  out  at  different 
epochs,  and  perhaps  embracing  different  forms  of  tubercle,  the  softening 
may  commence  at  any  part, — even  at  the  periphery.  This  fact  is 
fraught  with  interest,  as  corresponding  with  kindred  processes  in  certain 
other  morbid  products, — for  example,  the  central  softening  in  globular 
endocardial  vegetations, — in  intra-arterial  coagula-layers,  &c.  More- 
over, it  is  important  as  offering — if  at  this  time  of  day  it  be  wanting — a 
conclusive  argument  against  the  assumption  of  the  softening  of  tubercle 
being  a  process  evoked  from  without  through  the  agency  of  surrounding 
textures.  The  utter  absence,  in  tubercle,  of  bloodvessels  of  its  own,  the 
compression  and  closure  affecting  such  as  penetrate  the  larger  tubercle 
masses  from  without, — the  fact  that  in  textures  surrounding  tubercle 
engaged  in  incipient  softening  no  trace  of  inflammation  is  generally  dis- 
coverable,— that  both  the  latter  and  suppuration  supervene  only  upon 
completed  softening  of  the  tubercle, — lastly,  the  ocular  proof  that  the 
softening  commences  at  the  point  most  remote  from  surrounding  textures, 
are  so  many  arguments  against  the  assumption  referred  to,  and  espe- 
cially against  that  of  a  mechanical  melting  down  of  the  tubercle,  through 
pus  thrown  out  from  the  inflamed  encircling  textures. 

The  sum  of  these  negations  is,  that  the  softening  is  a  spontaneous 
metamorphosis  essentially  proper  to  the  nature  of  tubercle. 

The  softening  is  that  which  constitutes  (yellow)  tubercle  a  malignant 
growth,  inasmuch  as  it  commonly  leads  to  that  ulcerous  destruction  of 
the  textures  which  represents  tuberculous  phthisis. 

The  complete  solution  of  a  tubercle  determines  in  the  implicated  par- 
enchyma, a  gap,  generally  corresponding  to  the  tubercle  in  size,  replete 
with  so-called  tubercle-pus.  The  parenchyma  has  suffered  a  loss  of  sub- 
stance to  the  extent  only  of  the  texture  particles  which  happen  to  have 
been  involved  in  the  tubercle,  and  have  now  perished  in  the  tubercle-pus. 
This  gap  represents  the  primitive  tuberculous  cavity  within  a  paren- 
chyma. The  contact  of  the  tubercle-pus  with  the  surrounding. textures, 
occasions  a  corrosion  of  the  latter.  The  moderate  enlargement  of  the 
primitive  cavity  thus  engendered,  is  substituted,  upon  membranous  ex- 


TUBERCLE.  229 

pansions,  the  mucous  coats  for  instance,  by  a  deepening  destruction  of 
the  tissues  ;  that  is,  of  the  inner  stratum  of  the  mucous  membrane.  This 
manifests  itself  as  a  millet- or  hemp-seed-sized  ulcer,  which,  to  distin- 
guish it  from  the  different  form  arising  from  consecutive  enlargement, 
has  been  designated  as  the  primitive  tubercle-ulcer. 

The  consumption  of  textures  would  here  remain  inconsiderable,  but 
for  the  breaking  down  of  fresh  tubercle  in  the  proximity  of  the  original 
ulcer.  Inflammation  here  plays  an  important  part. 

(a.)  This  production  of  fresh  tubercle  in  the  vicinity  of  that  softened, 
and  of  the  resulting  primitive  cavity, — at  the  margin  and  base  of  the 
primitive  tubercle-ulcer,  upon  superficial  expansions, — determines  the 
enlargement  of  the  ulcer  in  all  directions, — the  textures  becoming  again 
and  again  corroded  and  necrosed  by  the  fresh  softening  tubercle.  And 
this  takes  place  with  a  rapidity  proportionate  to  that  of  the  softening  of 
the  secondary  tubercle — the  product  of  an  exalted  cachexia.  Another 
accidental  mode  of  enlargement  of  the  ulcer  consists  in  two  or  more 
ulcers,  already  advanced  in  the  way  described  beyond  the  primitive  con- 
dition, merging  in  a  single  one.  The  result  is  an  ulcer  marked  by  its 
irregular,  indented  form, — upon  mucous  membranes,  by  serrate,  jagged 
edges, — in  muco-membranous  canals  by  its  affecting  the  girdle  shape. 
The  manner  of  its  development,  and  its  characteristic  form,  so  different, 
especially  on  mucous  membranes,  from  that  of  the  primitive  ulcer,  fairly 
entitle  it  to  the  appellation  of  secondary  tubercle  ulcer. 

The  destruction  of  textures  involved  in  this  process,  as  corrosion  and 
necrosis  through  contact  with  tubercle-pus,  constitutes  the  tuberculous 
phthisis  of  organs.  These  are  either  acute  or  chronic. 

(b.)  Inflammation  enters,  as  we  shall  see  by  and  by,  into  various  re- 
lations to  the  phthisical  process.  What  we  have  here,  however,  particu- 
larly to  remark  upon  is  in  how  far  it  contributes  to  the  enlargement  of 
the  tubercle-ulcer  and  to  the  modification  of  its  character.  In  the  first 
place,  it  determines,  for  the  most  part,  yellow  tuberculous  products,  in 
the  form  of  infiltration,  which,  conformably  with  the  aggravated 
dyscrasis,  rapidly  break  up,  extensively  corroding  and  destroying  the 
textures  involved.  In  this  way  inflammatory  action  occasions  an  omi- 
nous enlargement  of  the  tuberculous  ulcer,  and  the  most  widely  spread 
tuberculous  ulceration  in  an  acute  form. 

In  the  second  place  it  engenders  organizable,  solidifiable,  fibrino-  or 
albumino-gelatinous  products,  which  pass  into  a  fibroid  callus.  Thus 
arises  the  callous  condensation  of  the  textures  encircling  the  cavity ;  in 
the  muco-membranous  tubercle-ulcer  (for  example,  in  the  bowel)  the 
hardish  elevated  brink  and  the  funnel-shape  of  the  primitive  ;  lastly,  the 
jelly-like  infiltration  and  induration  at  the  base  and  margin  of  the  secon- 
dary ulcer. 

These  products  exude,  according  to  circumstances,  either  pure,  or 
almost  pure,  or  combined  together  in  various  proportions.  In  worn-out 
individuals,  the  inflammation,  if  present  at  all,  furnishes  forth  thin, 
albumino-serous  products,  and  the  tubercle-ulcer  is  of  a  lax  and  torpid 
character.  In  the  proximity  of  cavities  seated  in  the  midst  of  tubercu- 
lous infiltration,  there  is  of  course  no  inflammation. 

3.   Cretefaction,  as  already  stated,  affects   fibrino-croupous  tubercle 


230  TUBERCLE. 

after  it  has  entered  into  the  softening  process.  It  is  co-significant  with 
the  cretefaction  of  fluid  blastemata,  and  analogous  with  the  cretefaction 
of  broken-down  fibrin  in  the  vegetations  and  coagula  within  the  vascular 
system,  in  croupous  exudates  upon  serous  membranes,  and  in  parenchy- 
mata ;  and  again  in  the  cretefaction  of  pus. 

The  basis  of  this  (secondary)  metamorphosis  is  as  little  to  be  sought 
extraneously  to  tubercle  as  the  softening  itself.  Nevertheless,  the  sur- 
rounding textures  may  contribute,  by  their  absorbing  agency,  to  the  in- 
spissation  of  tubercle-blastema.  What  cornification  is  to  the  gray, 
cretefaction  is  to  the  yellow  tubercle,  namely  a  process  of  involution. 

Cretefied  tubercle  resides,  for  the  most  part,  within  textures  isolated 
by  products  of  inflammation,  entering  into  a  fibroid  transformation  and 
then  cornifying  and  shrivelling  into  a  callous  capsule.  Both  together 
draw  down  upon  themselves  the  surrounding  textures  in  scar-like  corru- 
gations. 

Such  are  the  metamorphoses  of  genuine  tubercle  of  the  one  and  the 
other  form.  There  occur,  however,  complicated  met amor plw <ses  cor- 
responding to  various  combinations  of  the  different  tubercle-blastema. 
Thus: 

(a.)  The  combination  of  gray  with  yellow  tubercle  is  frequent.  Where, 
in  this  combination,  the  latter  passes  in{o  softening,  the  gray  tubercle, 
like  textures  in  contact  with  tubercle-pus,  becomes  destroyed.  Where 
the  softened  yellow  tubercle  cretefies  before  this  destruction  of  the 
gray  is  effected,  the  latter  cornifies  independently  ;  and  if  it  happen  to 
be  peripherous  to  the  other  it  encircles  the  cretefied  tubercle  with  a 
sheath  of  gray  cornified  tubercle,  differing  from  that  callous  exudate- 
capsule  which  results  from  inflammation  of  the  surrounding  textures. 

(5.)  Just  as  tubercle  blastemata  combine  with  one  another,  so,  in  like 
manner,  does  organizable  blastema  enter  occasionally  into  combination 
with  tubercle.  Its  existence  is  of  course  scarcely  demonstrable  in  yellow 
tubercle,  in  the  metamorphosis  of  which  it  becomes  itself  destroyed.  If 
cretefaction  set  in  early,  it  may  become  organized  so  as  not  to  be  easily 
distinguished  from  a  subsequently  effused  blastema,  the  product  of  in- 
flammation. 

The  combination  of  gray  tubercle  with  organizable  fibrin  is  more  sus- 
ceptible of  proof.  The  instances  are  not  rare  in  which,  hard  by  pure 
gray  tubercle,  granulations  are  found  in  which  one  portion  of  their  blas- 
tema is  in  progress  of  organization  to  a  fibrous  texture,  whilst  the  other 
abides  in  its  primitive  condition,  and  eventually  falls  into  decadence — 
cornifies. 

There  are,  indeed,  as  we  shall  presently  have  to  show,  granular  tu- 
bercles resulting  from  inflammation  upon  serous  membranes, — that  is, 
solidifying  exudates  or  granulations  as  big  as  poppy-seeds  or  millet- 
grains,  which  in  their  entirety  change  into  fibroid  textures — into  areolar 
tissue.  They  occur,  along  with  blastemata,  consolidated  into  pseudo- 
membranous  areolar  tissue,  or  along  with  gray  tubercle,  or  even  with 
both  gray  and  yellow,  softening  tubercle. 

The  organizing  of  these  granulations  consists  in  the  development  of  a 
more  or  less  determinate  fibrous  texture.  They  acquire  the  whiteness, 
the  resiliency  and  elasticity,  the  fibrous-torn  surface,  the  general  charac- 


TUBERCLE.  231 

ters  of  little  fibrous  tumors  ;  or  else  they  change  into  velvet-  or  felt-like 
fasciculi  of  connective  tissue. 

They  are  found  upon  the  peritoneum,  especially  of  the  liver  and 
spleen,  as  also  occasionally  upon  other  serous  membranes.  The  Pac- 
chionian  granulations  upon  the  arachnoid,  the  granulations  upon  the 
investment  of  the  ventricles  of  the  brain,  are  upon  the  whole  of  the  same 
character. 

It  is  intelligible,  from  hence,  in  how  far,  and  in  what  sense,  we  are 
warranted  in  speaking  of  a  textural  conversion,  an  organization  of  tu- 
bercle, as  a  metamorphosis  of  this  alien  growth.  It  is  intelligible, 
namely,  that  growths,  whatever  resemblance  they  may  bear  to  tubercle, 
lose  their  import  as  such,  in  other  words,  reveal  their  non-tuberculous 
character,  with  the  slightest  textural  conversion. 

Intimately  connected  with  the  above  is  the  question  as  to  whether  tu- 
bercle contains  bloodvessels  of  its  own?  The  question  may  belong 
rather  to  a  bygone  day.  It  is  for  the  present  day,  however,  to  set  this 
point  at  rest  for  all  time  ! 

Vascularity,  in  truth,  belongs  as  little  to  the  nature  of  tubercle  as 
organization  itself.  Still  it  is  undeniable  that  bloodvessels  are  sometimes 
met  with  in  tubercles.  Two  cases  are  here  possible.  In  the  first  case 
bloodvessels  may  appertain  to  textures  which,  whether  normal  or  patho- 
logical,— membranaceous  areolar  tissue,  for  instance, — had  become  in- 
volved in  the  tubercle  when  first  thrown  out.  One  or  more  bloodvessels 
may  traverse  the  tubercle,  previous  to  an  injecting  mass, — others  im- 
permeable. 

In  the  other  case  the  bloodvessels  penetrating  the  tubercle  are  doubt- 
less new-formed  vessels,  and  have  sprung  from  an  organizable  blastema, 
effused  together  with  the  tubercle  and  incorporated  in  it.  This  is  at- 
tested more  especially  upon  serous  membranes,  where,  as  a  consequence 
of  inflammation,  tubercle  becomes  deposited  along  with  a  considerable 
portion  of  blastema,  the  rudiment  of  vascularized  new  textures. 

To  sum  up  :  the  purer  the  tubercle,  the  more  certain  is  its  estrange- 
ment from  all  bloodvessel  formation.  The  less  pure,  that  is,  the  more 
organizable  blastema  it  has  incorporated,  or  consociated  with,  the  more 
susceptible  is  it  of  bloodvessel  formation. 

We  have  hitherto  spoken  of  tubercle  as  being  an  exudate, — a  secre- 
tion from  the  vascular  system  ;  of  which  we  hardly  deem  it  requisite 
to  furnish  proofs.  Here,  however,  a  double  question  suggests  itself, 
namely,  first,  concerning  the  seat  of  tubercle ;  and,  secondly,  concerning 
a  very  weighty  point,  namely,  the  local  process  of  tubercle  production. 

The  seat  of  tubercle,  as  exudate,  is  at  any  point  of  any  texture,  extra- 
neous to  the  bloodvessels.  Wherever  there  is  a  capillary  range,  a  de- 
position of  tubercle  is  possible.  The  seat  of  tubercle  is  without  doubt 
precisely,  or  at  least  in  close  proximity  to,  the  spot  of  its  exudation,  its 
blastema  being  in  the  highest  degree  coagulable.  It  is  most  probably 
for  this  reason  that  it  does  not  affect  textures  nourished  from  a  distance 
by  a  slow  imbibition  of  their  substance  with  plasma, — for  example,  car- 
tilage. We  can  ourselves  testify  to  the  occurrence,  both  in  larger 
bloodvessels  and  in  the  capillaries  (as  depots  or  metastases),  of  coagula 
obviously  of  a  tuberculous  nature.  These  are,  however,  only  excep- 


232  TUBERCLE. 

tional  cases,  and  the  doctrine  propounded  in  accordance  with  them  is 
founded  rather  upon  the  results  of  so-called  tubercle  created  by  artificial 
injection.  It  is  evident,  however,  that  the  tubercle-like  depots  so  formed 
were  due  either  to  infection  of  the  blood,  or  to  the  obstruction  of  blood- 
vessels, and  that  no  inference  can  be  drawn  from  them  as  to  the  spon- 
taneous formation  of  tubercle. 

Assuming,  therefore,  tubercle  to  be  an  exudate — an  effusion  out  of  the 
vascular  system — the  question  as  to  the  topical  process  would  resolve 
itself  into  this:  what  are  the  processes  in  whose  sequel  tubercle  is 
thrown  off  from  the  circulation  ?  To  this  we  can  only  reply,  that  tu- 
bercle, like  other  blastemata,  exudes,  now  almost  insensibly  in  the  act 
of  nutrition ;  then,  again,  in  the  sequel  to  obvious  (active)  hypersemia ; 
and  lastly,  as  a  consequence  of  still  more  manifest  inflammation. 

1.  It  is  a  fact  that  the  incipient  production  of  tubercle  takes  place, 
within  some  organ, — most  commonly  the  lung,  and  at   one  particular 
portion  of  it,  the  point  de  depart,  so  to  term  it,  of  tuberculosis, — in  a 
manner  almost  imperceptible  both  to  the  patient  and  to  the  looker-on. 
The  after-death  examination  reveals  no  inflammation,  or  such  only  as 
may  with  far  greater  probability  be  interpreted  as  consecutive.     The 
tubercle  is  for  the  most  part  the  gray,  withering,  and  only  now  and  then 
the  yellow,  softening,  cretefying  tubercle. 

2.  In  other  cases,  on  the  contrary,  a  marked  hypersemia  of  the  impli- 
cated organs  manifests  itself  during  life,  and  is  discoverable  after  death, 
as  the  source  of  the  tuberculous  exudation.     The  tubercle  is  deposited 
numerously,  and  also  rapidly. 

(a.)  This  tubercle  has  commonly  the  form  of  those  scattered  granula- 
tions, of  about  the  size  of  millet-seeds,  and  seldom  that  of  yellow  hemp- 
seed-  or  pea-sized  nodules. 

(6.)  Its  blastema  is  commonly  that  of  the  gray  tubercle,  often  com- 
bined with  that  of  the  yellow  ;  rarely  the  yellow  alone. 

(c.)  Not  only  is  it  thrown  out  rapidly  and  in  great  numbers,  either  all 
at  once,  or  in  successive  outbreaks  repeated  at  short  intervals  ;  but  it 
scarcely  ever  restricts  itself  to  a  single  organ,  and  whilst  seemingly 
perhaps  concentrating  its  main  forces  upon  some  one  organ,  it  assails 
several  others  simultaneously,  often  leaving  hardly  any  of  the  soft  paren- 
chymata  unscathed.  The  tubercles  are  marked  by  their  uniform  size 
and  character,  and  by  the  equable  distribution  with  which  they  are  scat- 
tered throughout  the  textures.  After  their  repeated  and  copious  exu- 
dation, they  gradually  become  less  firm,  softer,  glutinous,  until  the 
fibrinous  tubercle — the  fibrin  being  expended — changes  into  the  albu- 
minous tubercle. 

(d.)  The  effusion  of  the  tubercle  as  a  coagulable  blastema  is  always 
associated  with  that  of  a  non-coagulable  or  less  coagulable,  serous,  sero- 
albuminous,  jelly-like,  adhesive  product, — as  a  sort  of  vehicle  for  the 
first.  The  textures  are  manifestly  congested  ;  and,  around  the  tuber- 
cles, more  or  less  uniformly  infiltrated  with  the  product  just  referred  to. 

(e.)  The  more  generally  and  more  rapidly  the  tubercle-production 
extends  through  the  organism,  the  greater  the  multitude  of  tubercles, 
the  more  marked  those  dyscrasial  appearances  wrought  by  defibrination 
of  the  blood, — by  so  much  the  more  fully  does  the  general  disease  partake 


TUBERCLE.  233 

of  the  acute  character.  As  the  expression  of  that  defibrination,  the 
blood  appears  thin  and  watery,  the  attenuated  blood-serum,  tinged  with 
appropriated  hsematin,  being  thrown  out  upon  and  coloring  the  imbibed 
textures,  which,  if  highly  vascular,  appear  lax,  flabby,  and  drenched. 

(/.)  As  this  tuberculosis  for  the  most  part  proves  quickly  fatal,  a 
metamorphosis  of  the  tubercle  is  proportionately  seldom  observable. 

(g.)  Rare  instances  excepted,  this  tubercle  is  not  the  primitive  one. 
Tubercle  has  commonly  pre-existed,  whether  in  an  advanced  state,  or 
retrograding  to  decadence,  in  some  organ  or  other ;  for  instance,  the 
lungs  or  the  lymphatic  glands. 

3.  In  fine,  tubercle  is  frequently  thrown  out  in  the  sequel  of  inflam- 
mation. It  is  the  product  of  such  inflammation,  and  its  sole  distinguish- 
ing feature.  These  inflammations  occur  in  every  part,  but  more  par- 
ticularly upon  mucous  membranes,  and  in  the  larger  serous  sacs,  where 
they  may  be  most  advantageously  studied.  Thus  they  are  seen  especially 
upon  the  peritoneum  and  pericardium,  and  again  upon  the  mucous  mem- 
brane of  the  uterus,  of  the  tubse,  and  of  other  ducts,  as  the  vas  deferens, 
the  seminal  vesicles,  the  ureters.  They  very  frequently  affect  glandular 
hollow  formations — the  pulmonary  cells,  as  pneumonia,  the  follicles  of 
the  intestinal  mucous  membrane, — almost  equally  often  the  parenchyma 
of  the  lymphatic  glands,  fungoid  bones  or  sections  of  bones,  &c. 

The  exudate  offers  in  regard  to  its  so-called  tuberculization,  certain 
points  of  interest,  as  observed  most  particularly  upon  serous  tunics. 

(«.)  In  the  first  place,  only  a  portion  of  the  entire  exudate  appears  as 
tubercle,  whilst  the  remainder  becomes  gradually  reabsorbed  and  disap- 
pears. Or  else  this  latter  changes  into  a  texture, — to  areolar  tissue,  to  a 
fibroid  vascular! zed  texture,  often  to  a  redundantly  vascular,  fibro-cellular 
new  growth,  or  to  a  spurious  membrane  of  similar  structure.  The  two  allot- 
ments may  be  present  in  very  different  quantitative  proportions,  the  one 
or  the  other  predominating  in  various  measure.  The  more  texture- 
formation  prevails,  the  more  does  the  tuberculizing  portion  take  the  form 
of  scattered  miliary  granulations,  up  to  more  voluminous  nodules  im- 
bedded in  the  organized  new  growth.  The  more  scant  the  textural  forma- 
tion, the  more  prone  is  the  tuberculizing  portion  to  represent  a  confluent, 
uniform,  granulating,  stellate,  clavate  tubercle-mass  or  layer. 

The  tubercularizing  new  growths,  as  vascularized  pseudo-membranes, 
often  become  themselves  the  seat  of  inflammation,  for  the  most  part  pro- 
ductive of  hemorrhagic  exudates  of  a  tuberculous  nature. 

(b.)  In  the  second  case,  the  entire  solid  exudate,  remarkable  for  its 
bulk,  is  tubercle ;  or  the  organizable  portion  is  imperceptibly  small, 
and  disappears.  It  forms  in  considerable,  irregular,  shapeless  masses ; 
or,  on  membranous  expansions,  smooth,  or  stellate,  stella-clavate  layers. 

The  tubercle  thrown  out  as  a  consequence  of  inflammation,  is  the  gray, 
or  it  may  be  the  yellow,  or  again  a  combination  of  both.  The  fibrino- 
croupous  yellow  tubercle  is  especially  often  the  product  of  inflammation, 
and  especially  marked  by  its  abundance.  It  occurs  everywhere,  consti- 
tuting, upon  membranous  formations,  the  aforesaid  stellate  layers; 
within  muco-membranous  canals  and  cavities  of  inconsiderable  calibre,  as, 
for  example,  the  uterus,  the  tubre,  the  seminal  vesicles, — thoroughly 


234  TUBERCLE. 

closing  plugs;  in  compact  parenchymata, — lesser  or  greater,  roundish 
or  irregular  knobs ;  in  the  lung-cells  and  in  follicles, — smaller  coagula. 

Tubercle  produced  by  inflammation  generally  passes  speedily  into 
softening,  and  thus  to  a  phthisis  of  the  textures,  marked  by  the  acuteness 
of  its  course ;  and,  as  pneumonic  tubercle  infiltration,  by  the  jagged, 
eroded  look  of  the  cavities  ;  lastly,  by  the  not  unfrequent  supervention 
of  pulmonary  gangrene. 

Inflammatory  tuberculosis,  like  the  foregoing  species,  is  rarely  primary. 
It  generally  accedes  to  antecedent,  insensibly  generated  tubercle,  in- 
vading either  the  organ  already  diseased,  or  a  structure  intimately  con- 
nected with  it.  Thus  pneumonic  tubercle  and  tuberculous  pleurisy 
associate  themselves  to  pulmonary  phthisis ;  tuberculous  peritonitis,  to 
abdominal  tuberculosis  of  the  lymphatic  glands.  Or  else  tuberculoses 
become  consecutively  developed  according  to  the  same  scheme,  each 
fresh  one  bearing  more  and  more  decidedly  the  impress  of  its  inflamma- 
tory origin. 

The  ordinary  succession  of  the  different  fibrin-tubercles,  and  their 
different  modes  of  exudation,  partly  deducible  from  the  preceding  state- 
ments, are  highly  interesting.  Generally  speaking,  the  gray  tubercle, 
insensibly  effused  into  an  organ,  leads  the  way.  The  yellow  tubercle  is 
less  frequently  the  primitive  one.  Nor  is  the  hypersemic  or  the  inflam- 
matory oftener  the  primary  source  of  the*effusion  in  either  case.  Upon 
the  primitive,  insensible  deposition  of  gray  tubercle  follows,  with  in- 
creasing dyscrasis,  the  exudation  of  combined  gray  and  yellow  tubercle, 
the  yellow  progressively  assuming  the  ascendant,  until  it  ultimately 
exudes  alone.  Step  by  step  the  exudatory  process  becomes  more  and 
more  acute  in  character ;  hyperaemia,  inflammation,  and,  at  the  same 
time,  the  quantity  of  tubercle  thrown  out,  more  and  more  pronounced. 

Under  certain  conditions  there  exudes,  in  the  sequel  of  inflammation, 
more  particularly  in  a  new  growth  naturally  prone  to  tuberculization 
(pseudo-membranes  upon  serous  tunics),  a  tubercle  reddened  and  pig- 
mented  by  adherent  hsematin  and  embodied  blood-corpuscles.  It  might 
be  suitably  denominated  the  pigmented  or  hemorrhagic  tubercle. 

The  increment  of  tubercle,  as  a  consolidated,  non-vascular  exudate 
abiding  in  its  rude,  primitive  condition,  can  only  take  place  through 
adjacency  and  blending  with  a  mass  recently  exuded  in  its  immediate 
vicinity.  It  is  doubtless  thus  that  many  bulky,  lobulated,  stellate  masses 
have  become  aggregated  out  of  individual  tubercles,  dating  from  various 
periods. 

But,  whereupon  does  it  depend  that  the  product  of  the  said  processes, 
and,  in  particular,  that  the  product  of  inflammation,  in  other  cases  re- 
absorbed  or  transformed  into  textures,  is  here  precisely  tubercle  f 

We  do  not  consider  the  standing  explanation  of  this  phenomenon, 
namely,  of  the  persistence  of  the  exudate  in  its  primitive  rude  state, 
satisfactory.  It  is  to  this  effect : 

(a.)  The  lack  of  an  adequate  vitalizing  influence  in  the  surrounding 
textures,  and  in  the  entire  organism,  upon  the  exudate  (blastema).  To 
this,  it  may  be  objected  that  the  tubercle-blastema  remains  crude,  how- 
ever scanty  its  proportion,  and  however  unimpaired  the  energies  of  the 
surrounding  textures  and  of  the  entire  organism.  On  the  other  side,  we 


TUBERCLE.  235 

find  in  the  vicinity  of  diseased  parts,  and  this  in  persons  altogether 
debilitated  and  cachectic,  bulky  blastemata  forming  into  textures  both 
homoeoplastic  and  heteroplastic ;  even  into  textures  whose  development 
is,  generally  speaking,  very  easily  arrested ;  for  example,  bone-callus  in 
individuals  affected  with  osteo-malacia,  cicatrix  in,  and  in  the  proximity 
of,  ulcerating  textures.  "We  might  with  propriety  ask,  wherefore  does 
not  the  portion  of  an  exudate  farthest  removed  from  the  living  textures 
and  their  influence, — wherefore,  for  example,  in  exudates  upon  membra- 
nous expansions,  does  not  an  entire  layer  uniformly, — why,  in  the  midst 
of  exudates,  do  only  little  scattered  portions  abide  crude,  that  is  tuber- 
culize,  whilst  the  remaining  major  part  of  the  exudate  becomes  developed 
into  textures  ? 

(£>.)  The  lack  of  sufficient  moisture,  of  water,  in  the  blastema,  is 
alleged  as  the  condition  upon  which  tuberculization  depends. 

To  this  we  reply  that  tubercle-blastema  exudes  under  all  conditions, 
and,  not  at  all  rarely,  with  a  considerable  amount  of  water,  of  blood- 
serum.  A  primitive  lack  of  moisture  in  the  entire  exudate  cannot  there- 
fore determine  the  tuberculization,  the  tuberculous  nature,  of  its  coagu- 
lable,  solidifying  portion.  If  perfected  tubercle  be  poor  in  water,  it  is 
so  obviously  in  consequence  of  the  high  degree  of  solidification  of  its 
blastema.  This,  therefore,  namely,  its  high  degree  of  coagulability, 
might  be  the  cause  of  the  tuberculous  nature  of  the  exudate, — of  its  per- 
sistence at  its  primitive  stage  of  crudity.  This,  again,  might  be  the 
reason  why  the  tuberculous  exudate  takes  the  form  of  granulation.  In- 
flammatory products,  like  blastemata  generally,  seldom  exude  pure. 
Inflammatory  products  of  a  tuberculous  nature  are,  therefore,  ordinarily 
alloyed  with  others  of  a  different  kind.  Hence,  portions  of  the  former 
emerging,  by  reason  of  their  transcendent  coagulability,  from  their  com- 
binations with  the  latter,  appear  to  the  eye  in  the  shape  of  roundish 
coagula,  in  a  word,  of  tubercle. 

But,  again,  it  will  be  necessary  to  ask,  whereupon  does  this  high  grade 
of  coagulability  depend  ? 

It  can  but  be  founded  in  an  as  yet  unknown  dyscrasial  constitution  of 
the  fibrin,  as  tubercle-blastema.  There  are  blastemata  dry  from  primi- 
tive poverty  in  serum  ;  and  also  others  which,  parting  with  their  serum 
and  passing  into  a  high  degree  of  condensation,  nevertheless  do  not 
tuberculize,  but  become  developed  into  textures,  in  the  plenitude  of  their 
mass.  It  would  appear  evident,  therefore,  that  the  tuberculous  nature 
of  a  blastema  must  be  indwelling,  be  acquired  either  during  the  local 
process  (inflammation)  or  in  the  general  blood-disease  which  preceded 
and  prepared  its  exudation.  Accordingly,  tubercle  would,  as  once  be- 
fore stated,  have  to  be  interpreted,  now  as  a  local,  now  as  a  general 
affection. 

This  general  character  of  tubercle  is  the  more  marked  in  proportion  as 
its  mass  as  an  exudate  is  considerable ;  as  its  diffusion  through  the 
organism  is  extensive  ;  as*  its  characters  are  impressed  upon  any  spon- 
taneous coagula  formed  within  the  vascular  system;  and,  lastly,  as 
the  organism  in  its  totality  reflects  and  manifests  the  tuberculous  habit. 

Let  us  now,  as  a  sequel  to  the  foregoing,  discourse  respecting  that 
anomaly  of  the  crasis  upon  which  tubercle  is  based.  With  a  view,  how- 


236  TUBERCLE. 

ever,  to  establish  a  suitable  groundwork  for  the  exposition  of  the  tubercle 
crasis,  we  would  first  add  a  few  supplementary  remarks  concerning 
tubercle  itself. 

The  tubercle  crasis  is,  without  doubt,  a  fibrin-crasis — fibrinosis.  It  is 
not  this  in  respect  to  quantity  alone — hyperinosis — but  also,  and  this  is 
the  more  important  side  of  the  anomaly,  in  respect  to  quality.  This  is 
clear  even  from  that  varied  constitution  of  tubercle  upon  which  we  have 
founded  our  classification  of  fibrin-tubercle.  Besides  this,  the  fibrin 
must  have  become  impaired  in  a  particular  way,  in  order  to  qualify  the 
tubercle,  which,  in  the  one  case,  as  simply  fibrinous,  cornifies ;  in  the 
other  case,  as  fibrino-croupous,  does  not  undergo  the  rapid  process  of  dis- 
solution (puriform  liquefaction)  proper  to  croupous  fibrin. 

This  peculiar  vitiation  of  the  fibrin  may  itself  become  somewhat  modi- 
fied, or  admit  of  some  accessory  impairment.  And  this  may  operate  as 
the  cause  of  many  differences  in  tubercle,  recognized  to  this  day  only  by 
deviating  physical  properties ;  those,  for  instance,  of  coloration  and 
lustre,  of  consistence,  external  form,  mode  of  aggregation  of  the  granu- 
lations. &c.  Thus,  the  gray  tubercle-granulation  is  distinguished  at 
times  by  its  dingy  bluish  coloration,  by  a  grayish  lustre,  by  its  aggrega- 
tion in  sharply  defined  spheres  thinly  scattered  through  the  pulmonary 
texture;  the  yellow  tubercle  by  a  lardaceous  aspect.  The  croupous 
tubercle  effused  into  the  lung  during  the  inflammation  and  ichorous  off- 
throwing  of  cancers,  is,  owing  no  doubt  to  the  fundamental  cancerous 
vitiation  of  the  fibrin,  remarkable  for  its  whitish  coloration,  its  softer 
glue-like  consistency,  its  liquefaction  to  a  whitish,  cream-like  ichor. 

A  point  of  great  moment,  in  relation  to  the  crasis,  is  the  recognition 
of  an  impress  upon  general  nutrition  indicative  of  a  predisposition  to 
tubercle,  and  consisting  in  certain  developmental  proportions  of  textures 
and  organs;  in  a  word,  the  "tuberculous  habit."  Another  point  of 
equal  interest  is  the  relation  of  tubercle  to  other  morbid  processes,  bound 
up  with  primitive  or  consecutive  anomalies  of  the  crasis. 

There  exists  undeniably  a  habit,  expressed  in  a  delicate  construction 
of  the  soft  parts,  in  imperfect  development  of  the  muscular,  with  prepon- 
derance of  the  vascular,  system,  and  especially  in  a  so-called  phthisical 
build  of  the  thorax,  commonly  deemed  ominous  of  pulmonary  tubercle. 
It  is  essential,  however,  that  this  build  should  not,  according  to  the 
vulgar  notion,  be  imputed  to  smallness  of  the  lungs  within  a  seemingly 
insufficient  thorax,  but  rather  to  very  voluminous  lungs  within  a  thorax, 
the  obvious  narrowness  of  which,  in  its  antero-posterior  diameter,  is 
amply  compensated  for  by  its  length,  with  a  relatively  small  abdominal 
cavity,  and  small  abdominal  viscera. 

Nevertheless,  tubercle  does  not  always,  nor  exclusively,  thrive  upon  a 
substructure  like  this.  The  tuberculous  crasis,  like  the  local  tuberculosis 
of  an  organ,  may  become  acquired  in  an  individual  of  quite  a  different 
habit,  as  a  consequence  of  surpassing  external  and  internal  mischief. 

With  reference  to  the  second  point,  namely,  the  relation  of  the 
tubercle  to  other  morbid  processes,  no  disease  offers  so  much  that  is  in- 
teresting, that  is  corroborative  of  views  already  set  forth,  that  is  practi- 
cally serviceable  and  inductive  of  ulterior  research,  as  tubercle.  It  is 


TUBERCLE.  237 

especially  distinguished  by  its  exclusive  relation  towards  several  morbid 
processes. 

The  sum  of  an  immense  range  of  experience  in  point  is  to  the  follow- 
ing effect : 

1.  Cyst-formation,  as  a  new  growth,  is  rarely  found  concurrent  with 
tubercle,  either  in  the  same  organ  or  in  the  same  organism  generally.  In 
this  sense  the  proliferous   cyst-formations   are   distinguished.      Where 
their  seat  is  in  the  abdominal  cavity,  as  for  instance  in  the  ovary,  the 
immunity  against  tubercle  is  augmented  by  an  accessory  circumstance, 
in  itself  most  important,  namely,  the  coarctation  of  the  thoracic  space 
by  pressure  from  beneath. 

Experience  seems  to  show  that  it  is  more  common  for  cyst-formations 
to  succeed  to  the  extinction  of  tuberculosis,  than  the  converse. 

A  comparison  of  the  occurrence  of  both  in  the  various  organs  esta- 
blishes, as  the  extreme  points  of  the  scale,  the  well-known  great  frequency 
of  tubercle  against  the  extreme  rarity  of  cyst-formation  in  the  lungs, 
and  the  reversed  proportion  of  the  two  in  the  ovaries,  and  next  to  these 
in  the  salivary  glands.  This  relation  seems  highly  important  in  refer- 
ence to  the  affinity  which  cyst-formation  bears  to  sarcoma  and  carcinoma. 

2.  A  similar  antagonism,  as  shown  from  still  more  numerous  observa- 
tions,   prevails   between    tubercle   and    carcinoma.      Whenever    their 
general  correlation  is  susceptible  of  proof,  cancer  has  seemed  to  succeed 
to  tuberculosis,  tubercle  rarely  to  become  developed  after  the  extinction 
of  cancer  and  its  crasis.     Moreover,  it  must  be  repeated  that  to  cancer, 
and  in  particular  to  inflamed  and  ulcerating  cancer,  there  is  sometimes 
superadded,  more  especially  in  the  lungs,  a  tubercle,  marked  by  a  whitish 
coloration,   a  softish  glue-like  consistence,  and  a  tendency  to  resolve 
itself  into  a  whitish  cream-like  ichor.     It  has  the  import  of  tuberculo- 
croupous  impairment  of  a  carcinomato-dyscrasial  fibrin. 

A  corresponding  result  of  much  interest  is  afforded  by  a  comparison 
of  the  scale  of  frequency  of  cancer  and  tubercle,  as  well  as  of  several 
special  local  relations  of  both. 

They  are  diametrically  opposed  to  one  another,  as  thus : 

FREQUENT.  RARE. 

Lung  tubercle.  Lung  cancer. 

Ovarium  cancer.  Ovarium  tubercle. 

Salivary  gland  cancer.  Salivary  gland  tubercle. 

Stomach  cancer.  Stomach  tubercle. 

(Esophagus  cancer.  (Esophagus  tubercle. 

Rectum  cancer.  Rectum  tubercle. 

Ileurn  tubercle.  Ileum  cancer. 
&c.  &c. 

Again,  the  special  localities  present  many  differences  of  their  own. 
Thus,  in  the  uterus,  the  vaginal  portion  and  cervix  become  affected  with 
cancer,  whilst  tubercle  fastens  upon  the  mucous  membrane  of  the  body 
of  the  womb,  and  generally  stops  short  at  the  internal  orifice.  The 
epididymis  becomes  primarily  and  essentially  tuberculous ;  the  testis,  can- 


238  TUBERCLE. 

cerous.  In  the  lungs  the  upper  section  is  peculiarly  obnoxious  to 
tubercle,  whilst  cancer  occurs  at  every  part  of  the  lung-parenchyma. 
In  fine,  cancer  and  tubercle  possess  a  different  import  in  the  most  vari- 
ous organs  according  as  the  one  or  the  other  is  primitive  or  secondary. 
Thus,  cancer  of  the  liver  is  not  rarely  a  primitive,  tuberculosis  of  this 
organ  almost  invariably  a  secondary  affection,  if  not  a  mere  participa- 
tion of  general  tuberculosis. 

3.  Typhus  and  Tuberculosis. — Typhus  associates  itself  with  tubercu- 
losis only  under  the  influence  of  very  intense  epidemics ;  in  other  words, 
it  very  seldom  attacks  tuberculous  individuals.     On  the  other  hand,  a 
fibrino-croupous  tubercle-crasis  developes  itself  not  unfrequently  in  the 
sequel  to  typhus,  and  with  it  local  inflammation  with  fibrino-croupous 
exudation  of  a  tuberculous  nature.     This  occurs  in  the  shape  of  inflam- 
mations of  the  lungs,  and  also  of  such  follicles  of  the  ileum  as  have 
escaped  the  typhous  process.     This  determines,  from  the  softening  of 
the  tubercle  around  the  typhous  loss  of  substance,  a  combination  of  the 
so-called  typhous  with  the  tuberculous  intestinal  ulcer. 

This  tuberculosis  in  the  sequel  to  typhus  is  without  doubt  based  upon 
the  not  unfrequent  conversion  of  the  typhous  to  the  fibrino-croupous 
crasis.  The  conversion  takes  place  at  different  periods,  but  frequently 
at  a  very  early  stage  of  the  retrogressive  typhous  process. 

There  is  a  similar  relation  of  tuberculosis  to  the  acute  exanthemata  ; 
especially  to  scarlatina  and  measles.  The  tuberculosis  following  them 
is,  for  the  most  part,  fibrino-croupous,  and  dependent  upon  a  similar 
conversion  of  the  exanthematous  crasis. 

4.  Intermittent  Fever  and  Tuberculosis. — The  experience  of  foreigners 
places  their  incompatibility  with  each  other  beyond  any  doubt. 

5.  Bronchocele  and  Tuberculosis. — Although  within  the  range  of  our 
own  observation  a  moderate   degree  of  sporadic  goitre  has  not  seemed 
necessarily  to  possess  an  exclusive  relation  towards  tubercle,  the  obser- 
vations of  foreigners  as  to  the  exclusive  relation  of  endemic  goitre  to 
tuberculosis  merit,  nevertheless,  to  be  noticed  here.     Apart  from  the 
affinity  in  the  structural  relations  of  the  enlarged  thyroid  gland,  goitre 
presents,  in  the  outpouring  of  colloid,  important  points  of  analogy  with 
cysts,   sarcomata,   and  cancers,   in  which   colloid  often  constitutes   an 
essential  ingredient.     It  would  seem  that,  in  endemic  goitre,  it  is  not 
the  mechanical  hinderance  to  respiration  that  occasions  consecutively, 
but  an  anomaly  of  the  crasis  connected  with  the  secretion  of  colloid  in 
the  thyroid  gland,  that  determines  primitively  the  exclusion  of  tuber- 
culosis.    (See  Colloid.}      This  is  betokened  by  the   alienation  of  the 
general  habit  contracted  with  goitre,  and  still  more  by  the  fact  that,  in 
districts  where  goitre  is  endemic,  tuberculosis  does  not  occur,  even  in 
individuals  unaffected  with  the  prevailing  deformity. 

6.  Rickets  and  Tuberculosis  do  not  readily  combine.     Nay,  rachitic 
deformity  and  coarctation  of  the  thorax  are  scarcely  ever  found  com- 
plicated with  tuberculosis.     It  is,  as  yet,  undecided  whether,  or  what 
degree  of,  exclusiveness  towards  tubercle  absolutely  belongs  to  rickets ; 
and,  again,  whether  the  latter  owe  not  its  immunity  to  a  consecutive 
disproportion  of  its  own  creation,  namely,  the  deformity — the  narrowing 
— of  the  thorax. 


TUBERCLE.  239 

7.  Even    the   arterial   disease   upon   which   spontaneous   aneurism 
depends,  and  which  consists  in  the  endogenous  exudation  and  strati- 
fication of  a  fibrinous  substance  upon  the  internal  bloodvessel  membrane 
(see  Abnormal  Conditions  of  the  Arteries)  is,  in  its  more  highly  deve- 
loped grades,  very  rarely  associated  with  tuberculosis.     The  immunity 
is,  perhaps,  based  upon  an  exhaustion  of  the  materials  for  tubercle,  due 
to  the  deposition  of  a  solidifying  blastema  out  of  arterial  blood.     A 
more  decided  immunity  is  brought  about  by  aneurisms,  or  by  a  single 
extensive  aneurism,  in  the  proximity  of  the  heart,  involving  the  endo- 
genous coagulation  of  great  fibrinous  masses,  and  a  consequent  hydrse- 
mia  through  defibrination  of  the  blood. 

8.  The  relation  to  tubercle  of  venosity  (that  is,  an  habitual  prepon- 
derance of  venous  blood  in  the  system)  and  of  cyanosis,  as  resulting 
from  mechanical  hindrance  at  the  centres  of  the  organs  of  circulation 
and  of  respiration,  is  of  paramount  interest  and  even  of  great  practical 
importance.     The  remarkable  exemption  from  tubercle  brought  about 
by  these  conditions  induces  us  to  set  forth  the  relevant  facts,  as  nearly 
as  may  be,  in  their  natural  order.     They  determine  the  venous  consti- 
tution in  various  ways,  generally  conforming  in  this,  that  they  prevent 
the  arterializing  of  a  sufficiency  of  blood ;  whilst  they  engender  cyanosis 
by  hindering  the  return  of  blood  to  the  right  chambers  of  the  heart, 
the  said  blood  being  arrested  in  the  veins,  and  consequently  in  the  capil- 
laries generally.     The  relevant  facts,  ranged  in  a  twofold  series,  accord- 
ing as  the  venous  habit  and  cyanosis  are  dependent  upon  the  heart  or 
the  lungs,  are  as  follows : 

(a.)  The  first  place  is  due  to  the  fact,  confirmed  by  daily  experience 
and  convenient  as  a  starting-point  for  the  ensuing  considerations ; 
namely,  that  persons  laboring  under  enlargement  (dilatation,  hyper- 
trophy, and  their  complications)  of  the  heart,  whether  primary  or  super- 
induced by  mechanical  obstruction  at  its  orifices,  do  not  contract  tuber- 
culosis. 

(b.)  Nor  does  tuberculosis  co-exist  with  such  congenital  vices  of 
formation  in  the  heart  or  the  great  arterial  trunks  [absence,  insuffi- 
ciency, coarctation  of  either,  persistence  of  ductus  arteriosus,  &c.] 
which,  with  their  complications,  result  in  venosity  and  cyanosis,  and,  as 
the  anatomical  measure  of  their  significance,  in  augmented  volume  of 
the  heart. 

(c.)  Next  in  the  series  we  have  to  mention  the  immunity  afforded  by 
many  acquired  anomalies  of  arterial  trunks,  which  resemble  congenital 
vices  of  formation,  such  as  coarctation  from  compression,  obstruction, 
obliteration,  or  again  by  large  aneurisms  in  the  vicinity  of  the  heart. 
Apart  from  what  has  already  been  said  on  this  point,  the  immunity  is 
due  to  the  mechanical  impediment  which  the  overpowering  blood-column 
in  the  dilated  aortal  trunk  opposes  directly  to  the  emptying  of  the  left 
ventricle,  and  indirectly  to  the  influx  of  venous  blood  into  the  right 
heart. 

The  same  immunity  is  attained  in  venosity  and  cyanosis  owing  to 
hindrance  to  the  pulmonary  circulation;  more  especially  where  the 
impediment  reveals  its  serious  character  by  a  dilatation  of  the  right 
heart. 


240  TUBERCLE. 

We  may  here  further  adduce : 

(d.)  The  observation  that  the  increased  density  of  the  lungs  produced 
by  coarctation  of  the  thoracic  spaces,  in  higher  grades  of  lateral  curva- 
ture of  the  spine,  or  in  the  rickety  chicken-breast,  excludes  tuberculosis. 
Nay !  it  is  an  important  fact  that,  with  the  establishment  of  a  deformity 
of  the  spine  in  the  shape  of  gibbosity,  even  when  owing  to  tuberculous 
caries  of  the  vertebrae,  the  tubercle-crasis  is  forever  rooted  out  in  con- 
sequence of  the  narrowing  of  the  thoracic  spaces. 

(e.}  The  fact  that  the  compression  exercised  by  pleural  effusion,  and 
a  consecutive,  abiding  increase  of  compactness  of  the  one  lung,  as 
denoted  by  a  sinking  in  of  the  thorax,  in  like  manner  extinguishes  the 
tendency  to  tuberculosis.  This  effect  is  the  more  surely  produced,  the 
greater  the  mechanical  obstruction,  and  the  consequent  disproportion 
between  the  blood-mass  and  the  lung-capillaries  pervious  to  it ;  and  the 
less  competent  the  other  (vicariatmg)  lung  is  to  carry  on  the  function  of 
arterialization. 

(/.)  The  fact  that  pregnancy  arrests  the  progress  of  an  established 
tuberculosis ;  or,  as  we  would  correct  and  extend  this  proposition,  the 
fact  that  advanced  pregnancy  not  only  arrests  a  tuberculosis  already  in 
being,  but  also  obviates  the  formation  of  tuberculosis  generally.  It  is 
the  effect  of  that  embarrassment  of  the  thoracic  spaces,  and  of  that 
resulting  condensation  of  the  lung-parenchyma  occasioned  by  upward 
pressure  from  the  abdomen ;  in  other  words,  it  is  based  upon  a  venosity 
brought  about  by  mechanical  means.  It  is  probably  for  similar  reasons 
that  the  placenta  very  rarely, — the  foetus  perhaps  never,  becomes  tuber- 
culous. 

This  relation  derives  further  interest  from  the  rapidity  with  which, 
after  child-birth,  that  is,  after  removal  of  the  conditions  which  prevailed 
during  advanced  pregnancy,  fibrin-erases  with  their  respective  exuda- 
tory  processes,  and  amongst  them  the  tubercle-crasis  and  tubercle- 
deposits,  take  place,  more  particularly  through  the  medium  of  inflam- 
matory stasis. 

(g.)  To  the  same  class  is  to  be  referred  the  immunity  from  tubercle 
arising  from  every  enlargement  of  the  abdominal  space,  and  the  conse- 
quent narrowing  of  the  thoracic  cavity.  The  exemption  allotted  to 
patients  afflicted  with  vast  ovarian  cystoids  probably  partakes  of  this 
nature. 

(h.)  Again,  the  fact  that  even  congenital  smallness  of  the  pleural 
sacs,  paired  with  primitive  smallness  of  the  lungs,  and,  as  it  mostly  is, 
with  an  inverse  ratio  of  the  development  of  the  abdomen  and  its  viscera, 
serves  as  a  protection  against  tuberculosis. 

(i.)  That  in  the  earliest  childhood  (with  closed  foetal  passages),  owing 
to  a  condensed  state  of  the  lungs  caused  by  predominant  abdomen, 
tuberculosis  occurs,  if  at  all,  very  rarely. 

(k.)  The  exemption  apportioned  to  those  who  labor  under  chronic 
catarrh,  under  vesicular  emphysema  of  the  lungs,  or  under  bronchial 
dilatation,  was  recognized  even  by  Laennec.  The  empirical  recognition 
of  this  relation  has  even  led  to  attempts  to  cure  tuberculosis  by  the 
forcible  production  of  those  conditions.  The  real  preservative  point 
was,  however,  overlooked,  both  here  and  in  another  mode  of  cure  aimed 


TUBERCLE.  241 

at  by  others,  namely,  that  of  closing  cavities  in  the  lungs  by  forcible 
compression  of  the  thorax.  The  protective  and  curative  impulse  con- 
sists, even  here,  in  venosity.  And  this  venosity  is  a  consequence  of  the 
destroyed  function,  the  collapse  and  eventual  wasting  of  numerous 
pulmonary  lobules,  through  obstruction  of  their  bronchia  with  muco- 
purulent  secretion ;  in  bronchial  dilatation,  through  the  concomitant 
obliteration  of  considerable  portions  of  the  lung ;  in  emphysema,  through 
lost  contractility  of  the  pulmonary  texture  for  expiration,  and  conse- 
quently embarrassed  respiration,  more  especially,  however,  through  the 
destruction  of  extensive  ranges  of  the  lung-capillaries. 

(I.)  It  will  be  readily  understood  that  the  dropsical  crasis,  especially 
when  resulting  from  venosity,  excludes  tubercle. 

It  will  now  become  necessary  to  inquire  how  certain  exceptional  cases 
are  to  be  explained.  Individual  cases  of  the  kind  are  represented  in  tu- 
bercle associated  with  cancer,  or  with  venosity  mechanically  brought  about. 

(1.)  The  conditions  mentioned  as  excluding  tubercle,  operate  thus  only 
in  so  far  as  the  latter  is  based  upon  a  hyperinotic  crasis — an  excess  of 
fibrin.  This  does  not,  however,  prevent  the  small  fund  of  fibrin  accom- 
panying those  conditions  from  being,  under  favorable  circumstances,  ex- 
pended upon  tubercle  formation,  which  then  becomes  localized  in  a  pro- 
cess of  exudation. 

(2.)  The  tubercle  may  be  the  product  of  a  local  inflammation,  in  which 
the  fibrin  becomes  tuberculous. 

(8.)  The  entire  mass  of  fibrin  may  suffer  a  morbid  change,  effecting, 
as  intercurrent  disease,  a  consecutive  tubercle  crasis,  which  becoming 
exhausted  by  a  corresponding  exudation,  again  gives  way  to  the  original 
crasis. 

It  is  thus  that  genuine  tubercle,  when  concurrent  with  cancer,  may  be 
interpreted;  and  this  the  more  readily,  that  true  hyperinoses  and  fibri- 
nous  exudates  not  unfrequently  do  co-exist  with  cancer.  The  tubercle 
may  be  merely  local,  and  the  cancer  no  less  so.  It  may,  however,  be 
local,  and  yet  the  cancer  be  a  general  disease.  Or,  again,  it  may  be  the 
product  of  an  intercurrent  primitive  tubercle-crasis,  or  of  a  consecutive 
one  derived  from  a  local  process,  and  co-ordinate  with  those  hyperinoses 
and  fibrin-exudations  which  not  rarely  supervene  upon  inflamed  and 
ulcerated  cancer,  reflecting  a  secondary  crasis. 

(4.)  As  to  the  exemption  afforded  by  venosity,  there  is  no  doubt  that, 
to  render  it  complete,  a  high  degree  of  the  latter  is  requisite.  Since, 
however,  we  possess  no  scale  whereby  to  ascertain  directly  the  grade  of 
a  protective  crasis,  and  to  illustrate  the  exceptions,  we  must  inquire 
whether  it  be  not  possible  to  arrive  indirectly  and  approximative^  at 
this  recognition.  In  the  absence  of  such  a  scale,  certain  anatomical 
changes  must  serve  as  the  measure,  so  to  speak,  of  the  anomaly.  They 
consist  in  the  degree  of  heart  affection  (dilatation)  present,  this  furnishing 
an  available  criterion  for  the  amount  of  the  impediment  to  the  circula- 
tion, and  therefore  for  the  grade  of  the  venosity.  This  approximative 
index  with  the  aforesaid  inferences,  will  be  especially  applicable  where 
the  precise  extent  of  the  impediment  is  not  to  be  immediately  summed 
up  from  anatomical  data,  as  in  lung  affections,  like  catarrh  and  bronchial 
dilatation,  emphysema,  and  preternatural  density  of  the  lungs. 

VOL.  I.  16 


242  TUBERCLE. 

We  attach  importance  to  this  relation  of  tubercle  to  the  venosity 
resulting  from  mechanical  impediments  in  the  heart  and  lungs, — as 
affording  not  alone  proof  of  the  fibrin-crasis  being  the  foundation  of 
tubercle,  but  also  valuable  indications  for  medical  treatment. 

We  have  now  to  consider  the  relative  occurrence  of  tubercle  in  the 
different  organs  and  textures,  and  its  peculiar  processes  of  repair. 

It  will  be  expedient,  however,  as  a  preliminary  point,  to  determine 
what  is  signified  by  scrofula, — what  is  the  distinction — if  there  be  any 
— between  scrofulous  and  tuberculous  substance. 

For  our  own  part  we  hold  tubercle  and  scrofula  to  be  identical — tuber- 
culosis and  scrophulosis  to  be  one  and  the  same  disease ;  and  this  upon 
the  following  grounds,  namely : 

(a.)  One  and  the  same  elementary  composition,  both  anatomical,  and, 
so  far  as  investigation  has  gone,  chemical  also.  This  applies  with  especial 
force  to  scrofulous  substance,  as  compared  with  yellow  tubercle. 

Jb.)  Both  are  subject  to  the  same  metamorphoses,  namely,  softening 
cretefaction. 

(<?.)  The  tuberculous  and  the  scrofulous  ulcer  are  identical  both  in  the 
same,  and  in  different  organs ;  for  example,  the  scrofulous  skin-  and 
the  tuberculous  intestine-ulcer.  The  same  identity  attaches  to  their 
cicatrix. 

(d.)  Both  frequently  coexist  in  the  same  organ,  sometimes  without, 
sometimes  with,  the  appearances  of  inflammation. 

The  truth  is,  that  the  yellow  tubercle  is  commonly  called  "scrofulous 
substance,"  more  especially  when  it  occurs  in  largish  masses,  and  affects 
in  the  usual  way  the  glands — the  lymphatic  glands — in  children.  Thus 
the  same  substance  concurrently  affecting  the  lungs  and  the  bronchial 
glands  is  denominated,  in  the  one  instance  tubercle,  in  the  other  scrofula. 

A  scale  of  the  frequency  of  tubercle  in  the  various  textures  and 
organs,  offers  but  limited  points  of  interest.  According  to  our  experience 
it  would  present  in  adults  something  like  the  following  series,  namely : 

Lungs. 

Intestinal  canal. 

Lymphatic  glands,  more  particularly  the  abdominal  and  bronchial. 

Larynx. 

Serous  membranes,  especially  the  peritoneal  and  pleural. 

Pia  mater. 

Brain. 

Spleen. 

Kidneys. 

Liver. 

Bones  and  periosteum. 

Uterus  and  tubes. 

Testicles,  with  prostate  gland  and  seminal  vesicles. 

Spinal  cord. 

Striated  muscles. 

For  children  this  scale  does  not  answer  completely.  In  them  the 
lymphatic  glands,  together  with  the  spleen,  would  take  the  lead,  followed 
by  the  lungs  with  the  bronchial  mucous  membrane,  the  brain,  the  serous 
membranes,  &c. 


TUBERCLE.  243 

The  ensuing  remarks  appear  to  us  well  deserving  of  attention,  as 
affording  evidence  of  the  imperfection  of  any  summary  scale  of  fre- 
quency. 

(1.)  At  every  point  where  capillaries  occur,  there  may  be  tubercle. 
Epidermid  formations  and  cartilage  are  therefore  alone  exempt  from 
tuberculosis. 

There  are,  however,  vascularized  organs  in  which  tubercle  very  rarely, 
if  ever,  occurs ;  such  are  the  salivary  glands,  the  ovaries,  the  internal 
bloodvessel-membrane,  the  oesophagus,  the  vagina. 

Even  vascularized  new  growths  may  become  the  seat  of  tubercle. 
(2.)  If,  which  is  most  important,  we  consider  tuberculosis  individually, 
according  to  theft  primitive  or  to  their  secondary  appearance,  an  entirely 
different  scale  is  set  up.  The  lungs  and  lymphatic  glands,  it  is  true, 
retain  their  uppermost  rank,  but  are  immediately  followed  by  tubercu- 
loses, which  stand  very  low  in  the  foregoing  scale,  namely,  of  the  urinary 
system,  of  the  female  sexual  mucous  membrane,  of  the  bones,  of  the 
testicles  with  the  prostate  gland  and  the  seminal  vesicles.  Meanwhile 
tuberculoses  of  the  intestine,  of  the  larynx  and  trachea,  of  the  serous 
membranes,  of  the  spleen  and  liver,  take  a  very  subordinate  position  in 
the  new  scale,  seeing  that  they  seldom,  if  ever,  become  the  primary  seat 
of  tubercle. 

(3.)  Accordingly,  certain  tuberculoses  which  in  the  first  scale  occupy 
a  high  place,  possess  but  a  very  subordinate  nosologicnl  import.  They 
are  seldom,  if  ever,  primitive,  but  almost  always  secondary,  dependent 
upon  other  tuberculoses  often,  indeed,  only  participant  in  general  tuber- 
culoses. The  liver,  spleen,  kidneys,  nay,  in  many  cases  the  lymphatic 
glands,  stand  in  this  relation  to  tubercle. 

(4.)  Tuberculosis  almost  invariably  attacks  several  determinate  organs 
concurrently,  at  the  outset  or  at  a  very  early  period.  Of  this  commu- 
nion we  have  examples,  not  only  in  the  joint  tuberculosis  of  lymphatic 
glands  and  of  the  implicated  organs,  but  also  in  that  of  the  brain  and  of 
the  lymphatic  glands ;  of  the  testis,  prostate  gland,  seminal  vesicles,  and 
of  the  urinary  organs ;  of  the  spleen  and  supra-renal  gland,  and  of  the 
lymphatic  glands ;  of  uterine  and  tubal,  and  of  peritoneal ;  of  pulmonary, 
and  of  intestinal,  or  of  laryngeal  tubercle. 

(5.)  Secondary  tuberculoses  have  a  sort  of  groundwork  or  starting- 
point  in  certain  pre-existing  tuberculoses.  In  other  words,  secondary 
tuberculoses  accede  to  already  existing  ones  according  to  a  tolerably 
constant  rule.  Thus,  tuberculosis  of  the  lungs  or  lymphatic  glands 
offers  for  all  such  secondary  tuberculoses,  a  general  point  de  depart, 
whilst,  on  the  other  hand,  it  commonly  associates  itself  to  most  other 
tuberculoses.  Tuberculosis  of  the  serous  membranes  accompanies  that 
of  the  implicated  parenchymata ;  tuberculosis  of  the  urinary  system,  that 
of  the  genital  apparatus  in  the  male.  (See  "Tuberculosis,"  vol.  iv.) 

(6.)  Again,  the  mode  of  production  of  tubercle  varies  in  the  different 
organs.  Thus,  upon  serous  membranes  and  in  bone,  tubercle  is,  for  the 
most  part, — upon  mucous  membranes,  very  frequently, — in  lymphatic 
glands  and  in  the  brain,  not  unfrequently  the  product  of  inflammation. 

(7.)  In  fine,  it  is  worthy  of  note  that  in  every  organ  tubercle,  unless 
thrown  out  with  much  violence,  has  its  almost  invariable,  and  readily 


244  TUBERCLE. 

demonstrable  point  of  incipiency.  In  the  lungs  it  is  at  the  apex,  the 
upper  third  of  the  superior  lobes ;  in  the  pia  mater,  at  the  part  investing 
the  base  of  the  brain  within  the  common  groove,  running  from  the 
chiasma  to  the  pons  Varolii  and  the  medulla  oblongata  or  about  the  fossae 
sylvii ;  in  the  brain  itself,  in  and  about  the  gray  substance ;  in  bones,  in 
the  spongy  bones  or  parts  of  bones ;  in  intestinal  mucous  membranes,  in 
that  of  the  inferior  ileum ;  in  the  laryngeal  mucous  membrane,  at  the  por- 
tion covering  the  transversus  glottidis  muscle;  in  the  testicle,  in  the 
epididymis;  in  the  female  sexual  apparatus,  in  the  mucous  membrane  of 
the  tubes  and  uterine  fundus — that  the  deposition  of  tubercle  first  com- 
mences and  concentrates  itself. 

(8.)  Again,  there  are  a  few  marked  limitations  set  to  the  advance  of 
spreading  tubercle.  For  example,  tubercle  of  the  larynx  never  extends 
to  the  pharynx  ;  uterine  tubercle  hardly  ever  passes  beyond  the  internal 
orifice,  so  that  the  cervix  uteri  and  the  vagina  remain  exempt. 

Tuberculosis  very  commonly  proves  fatal,  if  locally,  by  impeded  func- 
tion, by  palsy  of  the  aifected  organ,  in  consequence  either  of  the  exten- 
sive, acute  deposition  of  tubercle  into  its  texture,  or  else  of  the  ulcerous 
destruction  of  the  latter  in  the  process  of  so-called  tuberculous  phthisis. 
Or  the  tuberculosis  may,  as  a  general  disease,  destroy  life  through  im- 
poverishment of  the  blood,  through  hydrsemia  or  the  serous  crasis,  an 
issue  vastly  favored  where  the  tubercle  is  copiously  and  at  the  same  time 
rapidly  thrown  out,  and  where  local  tuberculosis  in  important  organs 
hinders  the  reproduction  of  blood. 

The  cure  of  tubercle  may  take  place  in  various  ways.  Each  of  the 
metamorphoses  of  tubercle  may  become  invested  with  the  character  of  a 
healing  process.  Still,  neither  the  decadence  of  tubercle,  nor  its  ejec- 
tion through  the  medium  of  ulceration,  as  local  healing  processes,  are 
fraught  with  any  value  for  the  individual,  unless  accompanied  by  the 
extinction  of  the  fundamental,  tubercle-producing  crasis. 

The  cure  of  tuberculosis  as  a  general  disease — as  tubercle-dyscrasis — 
takes  place  now  and  then  obviously  through  the  intervention  of  some  of 
the  processes  and  conditions  already  adverted  to  as  excluding  tubercle ; 
at  other  times,  through  influences  entirely  occult. 

A  question  connected  with  the  local  healing  process  of  tubercle  here 
suggests  itself,  namely,  as  to  the  absorption  of  crude  tubercle  ?  The 
resorption  of  tubercle  as  formerly  believed  in,  was  probably  first  repu- 
diated by  Laennec,  and  after  him  by  most  pathologists ;  and  although 
valid  grounds  can  hardly  be  alleged  for  its  impossibility,  neither  has  it 
ever  been  proved  by  direct  evidence,  nor  is  it  at  all  within  the  compass 
of  likelihood. 

The  obsolescence,  the  cornification  of  gray  tubercle,  represents  incon- 
testably  its  readiest  process  of  involution.  As  a  direct  extinction  of  the 
tubercle,  it  would  afford  the  completest  cure,  did  it  not  concern  a  growth 
which  would  fail  to  become  destructive  if  it  abided  in  its  primitive  crude 
condition. 

Of  the  two  other  metamorphoses  aifecting  yellow  tubercle,  cretefac- 
tion  of  what  has  undergone  softening  unquestionably  presents  the  most 
desirable  process  of  repair,  as  will  become  evident  from  the  following 


TUBERCLE.  245 

remarks  concerning  the  other  metamorphosis,  considered  as  a  healing 
process,  or  as  the  basis  of  one. 

The  softening  of  tubercle  cannot  of  itself  serve  for  a  reparatory  pro- 
cess. The  elimination  of  softened  tubercle  through  the  instrumentality 
of  ulceration  in  its  vicinity,  can  alone  pass  current  for  such. 

But,  taking  into  account — 

(a.}  That  it  can  only  be  brought  about  by  ulcerous  destruction  of  the 
textures. 

(b.)  That,  although  the  aim  of  this  ulcerous  process  be  to  heal,  it  may, 
when  the  tubercles  are  numerous,  readily  induce  exhaustion. 

(c.)  That  the  attendant  inflammation — the  general  disease  being  un- 
extinguished — of  itself  determines  tuberculous  products,  thus  extending, 
without  limit,  the  ulcerous  consumption  of  the  textures. 

(d.)  That  even  under  favorable  crasial  conditions,  an  infection  of  the 
blood  is  possible  in  tuberculous  ulcers  (cavities). 

Taking,  we  say,  all  these  circumstances  into  account,  this  curative 
process  must  be  regarded  as  widely  subordinate  to  that  of  cretefaction, 
to  which  it  stands  in  nearly  the  same  relation  as  the  removal  from  the 
body  of  a  foreign  substance  by  a  debilitating  ulceration,  to  the  same 
substance  being  rendered  innocuous  by  incapsulation. 

The  healing  of  a  tuberculous  ulcer  or  cavity, — of  tuberculous  ulcera- 
tion,— can  therefore  only  take  place  provided  the  accompanying  inflam- 
mation, owing  to  extinction  of  the  tuberculous  crasis,  ceases  to  deposit 
fresh  tuberculous  matter,  and  determines  organizable  products  instead. 
The  loss  of  substance  is  made  up  for  by  new-formed  shrivelling  scar- 
texture.  Where  the  tubercle  has  not  been  completely  eliminated  in  the 
phthisical  process,  the  residue  may  become  isolated  by  a  pap-like  inspis- 
sation  and  eventual  cretefaction. 

ALBUMINOUS  TUBERCLE.    Acute  Tuberculosis. 

Under  this  denomination  is  understood  a  disease  presenting  many 
points,  both  of  resemblance  and  of  dissimilitude  with  the  tuberculoses 
already  discussed.  It  devolves  upon  us  to  investigate  these  analogies 
and  differences  ;  the  former  appearing  to  us  to  preponderate  so  far  as  to 
preclude  our  separating  the  disease  from  tuberculoses  generally. 

There  is  a  disease  which,  under  an  acute  course,  and  under  typhoid 
symptoms,  determines  a  tubercle  differing  in  many  respects  from  the 
fibrinous.  It  always  represents  solid,  mostly  poppy-seed-,  rarely,  if 
ever,  millet-seed-sized,  sometimes  limpid,  softish,  glutinous,  gray  granu- 
lations, either  of  vesicle-like  or  of  a  dull  transparency,  often  only  cogni- 
zable under  a  favorable  incidence  of  light ;  at  other  times,  although  far 
less  frequently,  opaque,  whitish,  or  whitish-yellow. 

On  a  closer  inspection,  this  tubercle  appears  marked  by  cell-formation. 
It  is  found  to  contain — 

(a.)  The  ordinary  nucleated,  exudate  cell,  in  considerable  numbers. 
b.)  Cells  with  two  or  three  nuclei. 
<?.)  Cells  with  filial  cell-formation. 
d.)  A  structureless  soft  basement  connecting  these  elements. 

It  exudes  always  in  great  abundance  under  the  symptoms  of  hyperse- 


246  TUBERCLE. 

mia,  in  scattered  granulations,  uniformly  distributed  through  the  paren- 
chyma of  the  affected  organ,  and  either  all  at  once,  or  at  intervals  rapidly 
succeeding  each  other.  A  manifest  equality  of  size  and  character  is 
observable  in  all  those  deposited  simultaneously,  or  during  the  same 
attack.  With  it  there  is  always  effused  a  grayish,  sero-albuminous  semi- 
gelatinous  humor,  with  which  the  diseased  textures  become  infiltrated. 

This  tuberculous  deposition  affects  not  only  entire  organs  or  large 
sections  of  organs  and  of  textures,  but  commonly  several  organs  and 
textures  simultaneously  or  in  rapid  succession ;  a  single  one,  however, 
generally  operating  as  the  main  point  of  concentration.  Its  seat  is  in 
the  lungs,  the  pia  mater,  especially  at  the  base  of  the  brain,  the  spleen, 
the  serous  membranes,  especially  the  peritoneum. 

This  tuberculosis  is  only  in  rare  instances  the  primitive  one.  For 
the  most  part,  it  is  based,  so  to  speak,  upon  a  precursory  fibrin  tubercu- 
losis of  the  lungs  or  lymphatic  glands.  In  these  cases  its  point  of  con- 
centration is  generally  either  the  organ  previously  affected,  or  some 
structure  standing  in  immediate  relation  with  it. 

The  disease  proves  fatal  through  palsy  of  affected  organs  essential  to 
life,  or  else  through  dyscrasial  influence. 

This  tubercle  is  subject  to  no  metamorphosis. 

The  dyscrasial  character  of  the  blood  is  manifest,  and  closely  assimi- 
lates to  the  exantheniatous  crasis.  (See  "  Crases.")  In  accordance 
with  it  are  the  livid  coloration  of  the  common  integument  in  the  dead 
subject,  the  dark  coloration  of  the  muscles,  the  general  appearance  of 
flabbiness,  the  serous  infiltration  of  the  parenchymata. 

In  this  description  of  the  disease  we  recognize  the  albuminous  crasis, 
and  a  product  which,  in  its  subordinate  coagulability,  its  soft,  gluey 
character,  its  cell-development,  gives  evidence  of  its  albuminous  nature. 

This  tubercle  renders  it  probable  that  albumen,  without  previous  con- 
version to  fibrin,  may  acquire  a  considerable  amount  of  coagulability, 
and  become  tuberculous  ;  nay,  that  where  the  opaque  yellowish  or 
whitish-yellow  acute  tubercle  does  not  form  upon  a  basis  of  croupous 
fibrin,  even  albumen  may,  without  conversion  into  fibrin,  acquire  the 
croupous  character. 

In  this  description  we  recognize  not  only  the  distinctions,  but  also  the 
analogies  between  the  fibrinous  and  the  albuminous  tubercle.  These 
analogies  stand  forward  the  more  prominently  if  we  recall  to  mind  the 
fibrin  tubercle  of  acute  production. 

Such  analogies,  apart  from  the  resemblance  in  outward  form  of  the 
two  heterologous  deposits,  that  is,  the  tubercle  form  ;  apart  from  the 
uniform  size  of  the  granulations  thrown  out  at  the  same  period  of  exu- 
dation ;  and  apart  from  their  equable  dissemination  through  the  paren- 
chymata ;  are  as  follows : 

fa.)  Both  are  rarely  the  primitive  tuberculoses  in  an  organism. 

(b.)  Both  are  thrown  out  under  manifestations  of  hyperoemia. 

(<?.)  With  both  there  is  effused,  as  a  sort  of  vehicle  for  the  coagulable 
portion  of  the  entire  exudation,  a  serous,  sero-albuminous  fluid. 

(d.)  Both  affect  the  same  organs  and  sections  of  organs. 

(e.)  The  albuminous  tubercle  bears  the  same  relation  towards  other 
diseases  as  the  fibrinous. 


ALBUMINOUS  CRUDE  BLASTEMATA.          247 

(/.)  In  by  no  means  rare  instances,  a  step-like  transition  from  the 
fibrinous  to  the  albuminous  tubercle  is  incontestable.  Upon  the  ground- 
work of  a  fibrin-tuberculosis,  which  has  undergone  frequent  phases  of 
phthisis,  there  exudes,  with  augmented  dyscrasis,  in  the  lungs  more 
particularly,  a  tubercle  which,  with  every  fresh  act  of  exudation  occur- 
ring in  rapid  succession,  becomes  softer  and  poorer  in  fibrin,  until  ulti- 
mately reduced  to  a  soft,  semi-fluid,  albuminous  tubercle, — a  consum- 
mated acute  tuberculosis. 

(#.)  Occasionally  we  discover,  especially  in  the  texture  of  the  pia  mater 
at  the  base  of  the  brain,  an  exudate  consisting  of  albuminous  tubercle 
and  tuberculizing  croupous  fibrin,  a  primitive  combination  of  the  two 
products. 

(h.)  Not  only  does  albumen  enter  into  the  composition  of  fibrin  tuber- 
cle, out  a  certain  amount  of  fibrin  modifies  that  of  the  albuminous 
tubercle.  A  complete  exclusion  of  the  one  or  the  other  is  hardly  con- 
ceivable, and  it  is  only  the  predominance  of  the  one  or  of  the  other  that 
characterizes  the  product.  Between  the  extremes  of  fibrinous  and  of 
albuminous  tubercle  there  exist  numerous  middle  and  transition  forms. 


ALBUMINOUS  CRUDE  BLASTEMATA. 

Under  this  head  we  shall  discuss  certain  products  in  their  nature  pro- 
bably albuminous,  and  essentially  distinguished  from  other  albuminous 
blastemata  by  their  persistence  in  the  condition  of  crudity.  Owing  to 
this  persistence,  as  also  to  their  being  founded  in  a  dyscrasial  element, 
we  rank  them  along  with  tubercle,  with  which,  moreover,  they  occur  not 
unfrequently  in  consecutive  alliance. 

They  are,  for  the  most  part,  solidified  blastemata,  resembling  to  the 
naked  eye  a  translucent  coagulated  albumen.  Now  and  then,  however, 
they  are  opaque,  and  of  a  turbid  whiteness.  They  consist  of  an 
amorphous,  glebous,  transparent  basement,  and  of  nucleus  formations. 

They  occur  in  certain  parenchymata  in  the  shape  of  infiltration — very 
rarely  in  that  of  a  collection  of  roundish  nodules  from  the  size  of  a  hemp- 
seed  to  that  of  a  pea.  The  liver,  the  spleen,  and  the  kidneys  are  known 
to  become  affected  with  these  infiltrations,  which  give  to  the  surface  of 
the  organ  a  brawn-like  aspect  with  a  transparent  margin,  frequently 
representing  a  spurious  hypertrophy  of  the  organs  named.  (See  "  Hy- 
pertrophy.") Whether  these  blastemata  occur  in  one,  or  in  several,  or 
in  all  of  those  organs,  they  mostly  occasion  considerable  enlargement 
thereof,  and  at  the  same  time  a  notable  change  in  their  consistency,  the 
parenchyma  becoming  compact  and  of  doughy  brittleness. 

The  out-throwing  of  these  blastemata  occurs  in  an  insensible  manner. 

In  point  of  fact,  they  comprise  that  partly  more  or  less  solidifying, 
whitish,  partly  viscidly  fluid  blastema  effused  into  the  parenchyma 
of  the  kidney  in  Bright's  disease,  particularly  in  certain  of  its  chronic 
forms. 

As  may  be  inferred  from  the  above,  and  as  experience  amply  confirms, 
these  blastemata  never  occur  but  in  connection  with  high  grades  of 
general  dyscrasial  disease ;  such,  for  example,  as  rhachitis,  mercurial 


248  UNORGANIZED    NEW    GROWTHS. 

cachexia,  inveterate  syphilis,  ague-cacliexia,  and  especially  certain  tuber- 
culoses. 

The  deposition  of  these  blastemata  is,  therefore,  never  a  local  affec- 
tion, but  invariably  indicative  of  an  anomaly  of  general  nutrition.  It  is 
clearly  dependent  upon  dyscrasis,  which  may  consist  in  an  excess  of 
albumen  in  the  blood,  and  be  either  primitive  or  secondary,  as  in  the 
tuberculosis  resulting  from  the  exhaustion  of  fibrin.  The  consequence 
of  a  copious  and  extensive  secretion  of  these  blastemata  is  the  eventual 
exhaustion  of  albumen,  and  a  watery  condition  of  the  blood  [hydrsemia], 
inductive  of  dropsy,  anaemia,  &c. 

These  blastemata  usually  abide  altogether,  and  throughout  in  their 
primitive  condition.  Occasionally,  however,  there  is  observable,  at 
certain  spots,  a  transformation  of  their  mass  into  molecular  fat.  They 
become  opaque ;  of  a  whitish  dulness ;  friable.  This  is  especially  the 
case  in  the  liver  and  kidneys,  and  it  is  not  improbable  that  cera-larda- 
ceous  infiltration  of  the  liver  is  the  result  of  a  progressive,  diffused  con- 
version of  this  albuminous  blastema. 


II.  UNORGANIZED  NEW  GROWTHS. 
A.— OF  UNORGANIZED  NEW  GROWTHS  IN  GENERAL. 

These  lack  both  the  internal  order  and  the  definite  forms  which  cha- 
racterize organized  new  growths,  and  their  development  comes  under  the 
dominion  of  chemical  laws.  Between  the  rudiments  of  what  is,  and 
what  is  not  organized,  there  is  no  distinction  in  point  of  form.  In  a 
chemical  sense  non-organized  growths  are  composed  both  of  unorganized 
and  of  organized  substances,  either  singly  or  conjointly,  and  it  is  even 
common  enough  for  a  new  growth  to  be  made  up  through  the  mechanical 
blending  or  interlacing  of  organized  with  unorganized  materials.  All 
these  considerations  taken  together  preclude  any  marked  discrimination 
between  the  two. 

There  are,  upon  the  one  side,  undoubtedly  new  growths  representing 
perfect  unorganized  formations,  for  example,  certain  concrements.  On 
the  other  side,  however,  non-organized  new  growths  originate  under  con- 
ditions and  forms  which  have  induced  us,  notwithstanding  their  unor- 
ganized nature,  to  discuss  them  along  with  the  organized  new  growths. 
We  may  instance  the  forth  issuing  of  lime-salts — as  cretefaction,  ossifi- 
cation, incrustation ;  of  the  free  fats ;  of  colloid ;  of  tubercle. 

The  material  for  non-organized  new  growths  in  general,  is  contained 
both  in  the  textures,  and  in  fluid  and  solid  blastemata ;  the  material  for 
a  special  order  of  non-organized  new  growths,  in  the  proper  fluids  of 
secretion.  Its  nature  varies  considerably.  It  consists  of  protein  sub- 
stances, certain  gluten-substances,  horn-substance,  fats,  pigments,  acids, 
salts.  In  a  more  extended  sense,  even  the  various  gases  and  fluids 
occurring  in  textures,  or  in  the  cavities  of  the  body  or  of  organs,  the 
fluid  of  genuine  dropsy  for  instance,  belong  to  the  class. 

Without  for  the  present  taking  these  last  into  the  account,  we  have  to 
observe  with  reference  to  unorganized  new  growths : 


UNORGANIZED    NEW    GROWTHS.  249 

The  elementary  forms  are  the  amorphous,  the  glehous,  the  laminate, 
the  granular  (down  to  the  finest  molecule  or  point-mass),  the  crystalline. 
Certain  substances  possess  a  determinate  form,  dependent,  however, 
for  the  most  part,  upon  their  peculiarity  of  composition,  upon  the  con- 
ditions under  which  they  become  severed  from  their  primitive  combina- 
tions, and  upon  their  mode  of  development.  Thus  protein  substances 
occur,  both  structureless,  and  in  a  glebous  or  a  molecular  form. 

These  materials  constitute  secondary  formations,  either  alone  or  with 
the  intervention  of  a  bond-medium,  for  example,  mucus.  This  is  often 
furnished,  together  with  the  external  moulding  or  form  of  the  new  growth, 
by  the  glutinous  basis  of  a  texture ;  for  example,  in  the  so-termed  ossifi- 
cation of  a  fibrous  tumor.  Both  in  form  and  size  they  manifest  great 
variety,  not  readily  susceptible,  however,  of  generalization.  We  allude 
more  particularly  to  calculous  concretions !  In  consistency  they  are  in 
various  degrees  soft  or  firm. 

Above  all,  their  chemical  composition  varies  greatly.  As  regards 
concretions  and  calculi,  these  readily  divide  into  two  groups,  namely,  into 
such  as  form  out  of  fluids  of  secretion,  and  consist  of  the  respective  com- 
ponents of  those  fluids,  and  into  such  as  become  developed  out  of  blaste- 
mata  and  textures.  These  last  have  a  composition  corresponding  with 
their  base,  and  very  commonly  consisting  of  phosphate  and  carbonate  of 
lime,  and  of  magnesia. 

Respecting  the  origin — the  mode  of  production — of  non-organized  new 
growths,  it  may  be  stated  generally — 

1. -They  are  exudates  or  secretions  in  a  primitive  form  of  non- 
organization,  as  exemplified  in  crude  fibrin,  and  encysted  colloid  and  fats. 

2.  They  are  the  result  of  various  transformations  of  such  products. 
To  this  order  belong  r 

(a.)  Formations  arising  out  of  the  conversion  of  exuded  and  secreted 
protein  materials  into  glutinous,  into  horny  substance,  into  fat ;  for  ex- 
ample, the  conversion  of  fibrin  and  albumen  to  colloid,  to  horny  substance, 
to  fat  in  the  molecular  or  crystalline  form. 

(b.)  Formations  arising  out  of  a  process  imitating  ossification  in  fluid 
or  solidified,  unorganized  or  textural  bases ;  a  liberation  of  lime-salts 
(phosphate  and  carbonate)  out  of  their  primitive  combinations,  as  crete- 
faction,  ossification,  lime-incrustation,  concretion.  (See  "Bone  Forma- 
tion.") 

(c.)  Formations  brought  about  by  a  more  palpable  deposition  of  all, 
or  only  of  certain,  components  of  a  fluid  in  which  they  are  held  in  solu- 
tion or  suspension.  They  are  most  especially  prone  to  form  in  secreted 
fluids,  and  either  consist  purely  of  specific  ingredients  proper  to  them, 
or  occur  blended  with  other  elements.  They  constitute  calculous  concre- 
tions. The  cause  of  their  separation  is  manifold.  It  may  be  that  the 
fluid  has  become  more  concentrated,  for  example,  by  loss  of  water,  their 
solvent  medium,  through  exosmosis  (resorption)  or  more  especially  by 
evaporation.  Again,  we  may  mention,  besides  the  precipitation  from 
fluids  of  certain  specific  components,  the  inspissation  and  exsiccation  of 
secreted  and  exuded  fluids  in  their  totality ;  for  instance,  of  mucus,  of 
ear-wax,  of  the  smegma  prseputii,  of  the  bile,  of  exudate,  of  pus,  &c. 
Or  else  it  is  a  consequence  of  a  chemical  conversion  of  the  fluid, — of  the 


250  UNORGANIZED    NEW    GROWTHS. 

solvent,  or  of  the  dissolved  substance.  For  instance,  the  free  acid  of 
normal  urine  retains  the  phosphatic  earths  in  solution ;  when,  however, 
the  urine  is  rendered  alkaline,  be  it  by  the  presence  of  mucus  or  exu- 
date,  or  by  conversion  of  the  urea  into  carbonate  of  ammonia,  the  phos- 
phatic earths  become  precipitated.  If  the  lithates  present  in  the  urine 
become  decomposed  by  an  excess  of  acid  in  the  urine,  the  lithic  acid,  as 
the  less  soluble,  is  thrown  down.  The  soluble  phosphate  of  magnesia 
present  in  almost  all  the  fluids  becomes  precipitated,  the  moment  that  it 
enters  into  a  combination  with  ammonia,  to  ammonio-phosphate  of  mag- 
nesia. 

Unorganized  new  growths  possess  sometimes  a  local,  sometimes  a 
general  import.  Thus,  urinary  calculi  may  be  the  result  either  of  mere 
local  contingencies,  or  of  various  anomalies  of  general  nutrition,  that  is, 
of  a  dyscrasial  process. 

B.— OF  UNORGANIZED  NEW  GROWTHS  IN  PARTICULAR. 

We  have  here,  in  the  first  place,  to  bring  forward  and  to  examine  in 
detail  the  substances  which  constitute  new  growths. 

1.  Protein  substances. — The  primitive  form  in  which  these  emerge 
from  their  solutions,  is  that  of  a  structureless  or  glebous  mass,  in  various 
degrees  of  coagulation,  and  that  of  an  elementary  granule  down  to  a 
pulverulent  point-mass.     The  reason  for  their  appearance  in  these  forms, 
that  is,  the  reason  for  the  general  coagulability,  and  d  fortiori  for  their 
specialities  of  form  and  coagulation,  is  quite  obscure.     That  which  spon- 
taneously undergoes  rapid  and  firm  coagulation  passes  current  for  fibrin ; 
that  which  coagulates  more  slowly  and  less  perfectly  under  a  manifest 
progressive  change  in  the  medium  of  solution,  for -albumen.     The  mole- 
cular form  appertains  in  particular  to  the  higher  grades  of  oxidation  of 
the  protein  substances  (croupous  and  pyin-holding  fibrin).     Since  the 
influences  which  produce  the  coagulation  and  precipitation  of  albumen 
in  experiments,  do  not  presumably  take  place  within  the  organism,  the 
discovery  of  the  modifications  suffered  by  albumen  through  the  agency 
of  water,  acetic  acid,  and  the  like,  is  highly  deserving  of  attention. 

The  protein  deposits  are  insoluble  in  ether  and  in  mineral  acids.  By 
acetic  acids  they  are  rendered  translucent,  and  ultimately  dissolved. 
By  caustic  potash  and  fuming  hydrochloric  acid  they  are  slowly  dissolved 
— by  the  latter  with  a  lilac  tint.  An  aqueous  solution  of  iodine  colors 
them  yellow. 

The  glutinous  and  horny  substances  emerging  out  of  the  protein-sub- 
stances are  amorphous,  or  have  a  glebous  or  a  stratiform,  elementary 
composition.  In  their  physical  properties  they  approximate,  more  or 
less,  according  to  their  grade  of  perfection,  to  gluten  and  to  urea ;  in 
their  chemical  reaction,  to  various  modifications  of  gluten  (gluten, 
chon drin,  pyin,  &c.),  and  of  urea. 

2.  Fats. — Their  elementary  form  of  occurrence  is  that  of  drops,  or  of 
an  amorphous  solidification  ;  of  granules  ;  of  crystals.     Little  is  known 
concerning  the  nature  of  fats  originating  thus,  more  especially  of  those 
assuming  the  form  of  granule  (elementary  granules,  both  free  and  in- 
celled,  discrete  and  aggregate),  or  developed  out  of  blastemata  and  tex- 


UNORGANIZED    NEW     GROWTHS.  251 

tures  through  conversion  of  protein-substances,  and  probably  even  of 
gluten. 

The  fats  cognizable  by  their  form  and  chemical  relations  are  : 

(a.)  Elain. — It  occurs  in  variously-sized  drops,  both  free  and  incelled. 
In  this  form  it  is  usually  set  free  out  of  emulsion-like  compounds ;  in  the 
form  of  elaic  acid,  out  of  saponaceous  compounds,  or  out  of  combinations 
with  other  fats,  for  example,  in  exudates,  in  medullary  carcinoma.  It 
frequently  represents  an  effusion  of  the  contents  of  fat-cells,  consequent 
upon  gangrenous  or  ulcerous  destruction.  The  drops  resist  the  action 
of  water  and  of  acids,  but  dissolve  on  being  boiled  with  potash,  and  still 
more  readily  in  ether  or  heated  alcohol. 

(b.)  Margarin  and  margaric  acid. — These  occur  in  microscopic 
needle-cyrstals,  for  the  most  part  aggregated  in  stellate  groups  or  bun- 
dles. In  this  shape  the  margarin  emerges,  after  the  body  has  become 
cooled,  from  its  solution  in  elain,  either  within  the  fat-cells,  or  without. 
The  crystals  of  margaric  acid,  soluble  in  concentrated,  heated  alcohol, 
are,  according  to  Vogel,  probably  a  product  of  decomposition,  wrought 
out  of  the  margarin  of  the  fat,  it  may  be,  by  a  free  acid,  so  often  deve- 
loped in  gangrene. 

(<?.)  Cholesterin. — When  cognizable  as  such,  it  occurs  in  tabular 
crystals,  representing  rhombic  planes.  Many,  however,  of  the  aforesaid 
fat-granules  are  likewise  cholesterin.  It  almost  always  occurs  along 
with  other  fats,  and  often  very  copiously ;  for  instance,  in  gall-stones,  in 
the  atheroma  of  arteries,  in  encysted  tumors.  The  fact  of  cholesterin 
so  frequently  occurring  in  fluid  and  solidified  protein  substances  during 
their  disintegration, — as  in  exudates,  in  tubercle,  in  stratiform  coagula 
upon  the  inner  coat  of  arteries,  renders  it  probable  that,  like  other  fats, 
it  is  the  product  of  a  decomposition  of  the  elements  of  those  substances. 
This  seems  to  us  more  probable  than  that  it  exists  preformed  in  combi- 
nations which  cause  it  to  be  held  in  solution.  Its  detection  in  the  blood 
does  not  appear  to  us  a  valid  objection  to  this.  It  is  soluble  neither  in 
water,  nor  in  acids,  nor  yet  in  alkaline  solutions,  but  only  in  ether  and 
heated  alcohol. 

(d.)  Stearin. — Its  occurrence  is  not  proved  with  certainty,  although, 
under  certain  conditions,  in  which  fat  assimilates  to  the  suet  of  the 
wether,  not  quite  improbable. 

3.  Pigments. 

(a.)  Black,  brown,  russet-yellow  pigment  (See  "Pigment"),  in  the 
shape  of  molecular  granules ;  the  last  two  occur,  also,  adherent  to  micro- 
scopic crystals  of  ammonio-phosphate  of  magnesia. 

(b.)  Bile-pigment,  as  a  finely  granular  precipitate  of  a  yellow-brown 
color,  insoluble  in  water  and  in  most  of  the  acids, — soluble  in  a  boiling 
potash-solution,  with  a  greenish-brown  tint.  Nitric  acid  destroys  it, 
after  causing  it  to  pass  through  phases  first  of  green,  then  of  blue,  and 
lastly  of  red  coloration. 

4.  LitJiic  acid  and  lithates. 

(a.)  Lithic  acid. — The  fundamental  type  of  its  crystals  is  the  rhom- 
boid prism,  which,  however,  often  appears  cut  down  to  a  rhombic  plane. 
The  crystals,  frequently  seen  grouped  into  rosettes  (Simon  and  Vogel), 


252  UNORGANIZED    NEW     GROWTHS. 

are  difficult  of  solution  in  water,  insoluble  in  acids,  alcohol,  and  ether. 
Potash  causes  their  gradual  solution.     They  occur  in  the  urine. 

(b.)  Lithate  of  ammonia,  as  a  finely  granular  precipitate,  colored  of  a 
dingy  yellow,  yellow-red,  russet,  rose-tint ;  difficult  of  solution  in  cold 
water ;  less  so  in  hot.  The  effect  of  acids  is  to  isolate  the  lithic  acid, 
which,  under  the  microscope,  is  then  seen  to  develope  its  crystals. 

5.  Lime-salts. 

(a.)  Basic  phosphate  of  lime,  as  a  gelatino-granular  mass,  soluble  in 
acids.  It  occurs  both  in  fluids  and  in  solidified  formations,  in  a  soluble 
combination  of  protein-substances,  with  gluten,  out  of  which  it  separates 
— especially  in  the  shape  of  cretefaction  and  ossification — in  the  form  of 
molecule. 

(b.)  Carbonate  of  lime,  in  the  shape  of  granular  deposition, — in  the 
cell-incrustation,  of  stratefaction — either  alone  or  in  union  with  the  fore- 
going substance.  Soluble  in  acids,  with  effervescence. 

(c.)  Oxalate  of  lime,  in  octohedral  crystals,  sometimes  remarkably 
minute ;  insoluble  in  water,  alcohol,  ether,  acetic  acid ;  soluble  in  hydro- 
chloric acid.  Found  in  the  urine. 

6.  Ammonio-phospliate  of  magnesia,  in  crystals  of  various  shapes. 
When  rapidly  formed,  they  cluster  together  in  stellate  groups  of  needle- 
shaped  crystals,  or  represent  denticulate,  Jeaf-like  forms.     When  slowly 
developed,  they  constitute  trilateral  prisms,  in  which  both  angles  corre- 
sponding to  the  same  lateral-edge  are  truncated.      The  crystals  are 
readily  soluble  in  acids — even  in  acetic  acid.     The  occurrence  of  this 
salt  is  extremely  frequent.     Wherever  a  development  of  ammonia  takes 
place,  the  wide  dissemination  of  phosphate  of  magnesia  determines  the 
formation  of  the  insoluble  triple  phosphate. 

7.  Sulphuret  of  iron,  in  molecular  granules,  soluble  in  acids  and  pre- 
cipitable  out  of  these  by  means  of  sulphuret  of  soda. 

Such  are  the  principal  and  the  better  known  substances  which,  inde- 
pendently of,  or  in  combination  with,  others,  compose  the  bulky  un- 
organized formations,  as  so-called  concretions  or  concrements.  We 
shall  treat  of  these  generally ;  dividing  them  into  two  great  series,  namely : 

1.  Into  such  as  are  essentially  protein-substances  ;  or  into  such  as 
consist  of  gluten  or  horn-like  substance,  of  fat,  and,  lastly,  of  the  phos- 
phates and  carbonates  of  lime  and  magnesia  ;  it  matters  not  whether  the 
latter  be  directly  thrown  out  as  such,  or  whether  they  have,  as  usual, 
become  obviously  developed  out  of  the  former,  that  is,  out  of  the  pro- 
tein-substances. 

2.  Into  such  as  have  comparatively  a  varied  composition,  and  are 
marked  by  the  specific  substances  which  they  contain. 

FIRST   SERIES. 

(a.)  Protein  concretions,  as  coagulations  within  the  bloodvessels — 
vegetations  ;  as  exudates  in  parenchymata,  upon  membranous  surfaces ; 
as  free  bodies  in  serous  cavities,  tubercle,  &c. 

(b.)  Accumulations  of  gluten-like,  colloid  substance,  commonly  within 
cyst-spaces ;  and  cornified  protein  concretions,  for  example,  of  the  valve- 
vegetations  in  the  heart. 


UNORGANIZED    NEW    GROWTHS.  253 

(<?.)  Fat,  as  the  cyst-contents ;  or  as  accumulations  within  serous 
cavities  ;  in  parenchymata,  in  the  shape  of  spherical  or  irregular  masses. 
Frequently  in  combination  with  the  following,  namely : 

(d.)  Bone-earth  concretion,  so-called  cretefaction  and  ossification,  as 
developed,  not  alone  in  the  protein  and  gluten-holding  unorganized  base- 
ments already  adverted  to,  but  also  in  fibroid  and  cartilaginous  textures, 
in  a  mode  and  form  which,  together  with  their  relations  to  the  normal 
ossification  of  bone-cartilage,  we  have  discussed  in  another  part  of  this 
volume.  [See  "  Bone  Formation."] 

The  concretions  consisting  of  litliate  of  soda,  found  in  the  sheaths  of 
tendons,  within  capsular  ligaments,  even  in  the  spongy  texture  of  the 
articular  terminations  of  bones,  constitute  an  exception  only  as  regards 
the  nature  of  the  substance  itself. 

The  significance  of  concretions  of  this  series  differs  with  the  organ 
affected ;  thus,  concretions  on  the  heart's  valves  are,  perhaps,  the  most 
important  of  all. 

SECOND   SERIES. 

To  this  series  belong  the  concretions  in  and  arising  from  fluids  of 
secretion.  We  divide  them  into  two  species  : 

(a.)  They  result  from  the  precipitation  of  one  or  of  several  of  the 
specific  components  of  a  secretion,  animal  matter  entering  into  their  com- 
position for  the  most  part  only  in  small  quantity  and  by  way  of  a  bond 
medium. 

They  constitute  the  genuine  stony  concretions  or  calculi,  which,  when 
diminutive,  are  termed  gravel  or  sand. 

The  size  of  calculi  is,  as  may  be  inferred  from  what  was  just  stated, 
extremely  various,  from  that  of  a  fine,  just  perceptible  sand-grain,  to 
that  of  a  concretion  filling  up  the  largest  secretory  canals  and  reservoirs. 

In  smaller,  solitary  concretions  the  form  is  mostly  the  spherical ; — in 
larger  ones,  it  corresponds  to  that  of  the  said  canals  and  reservoirs,  as 
in  the  instance  of  renal  calculi,  and  is  subject  to  much  modification. 
Where  many  concretions  co-exist,  they  acquire  from  reciprocal  pressure 
and  friction,  the  most  varied,  polyedrical  shapes, — as  in  the  case  of 
urinary  calculi,  and  especially  of  gall-stones.  Their  surface  is  smooth, 
polished,  or  else  knobbed  and  uneven,  stellate,  thorny,  rough. 

Their  consistence  mainly  depends  upon  their  chemical  composition. 

They  reside  at  large  in  their  respective  cavities,  or  else,  filling  the 
latter,  they  lie  firmly  impacted.  Or  again,  they  adhere  as  if  glued  or 
soldered  at  some  point,  through  the  medium  of  fibrinous  exudate. 

Their  structure  varies  extremely.  At  their  nucleus  they  exhibit  an 
agglomeration  of  an  amorpho-granular  precipitate.  Or  again,  they 
consist  of  concentrical  strata  of  the  same  character,  or  else  of  a  crystal- 
line precipitate  ;  or  lastly,  they  are  altogether  of  crystalline  fabric,  as 
in  the  case  of  certain  lithic  acid  calculi,  but  particularly  of  cholesterin 
concrernents  in  the  gall-bladder. 

The  first  impulse  to  their  formation  is  sometimes  given  by  foreign 
bodies  introduced  from  without,  or  by  coagulate, — endogenous  products. 
The  concretions  represent,  in  the  first  instance,  incrustations  of  things 


254  PNEUMATOSES    AND    DROPSY. 

in  various  degrees  alien  to  their  composition.  Thus,  for  example,  on 
the  one  side,  a  great  variety  of  foreign  bodies  which  have  lapsed  into 
the  urinary  bladder,  give  rise  to  lithic  acid  calculi ;  on  the  other  side, 
inspissated  bile,  or  bile-pigment,  to  cholesterin  calculus  in  the  gall- 
bladder. 

To  this  category  belong  lithic  acid  calculi,  salivary  calculi,  lachryma- 
tory calculi,  prostatic  calculi,  gall-stones,  many  intestinal  concretions. 

(b.)  They  are  due  to  the  inspissation  and  desiccation  [through  exos- 
mosis  or  evaporation]  of  some  fluid  of  secretion  either  within  or  exter- 
nally to  its  secreting  canals  and  cavities.  Here  the  concrement  consists 
of  the  ingredients  of  the  secretion  in  their  totality,  including,  of  course, 
a  considerable  amount  of  so-called  animal  matter,  and  with  it  of  or- 
ganized elements.  Proportionately  to  the  degree  of  inspissation,  the 
concrement  is  soft ;  or,  it  may  be,  of  a  stony  hardness.  Concretions  of 
this  kind  very  often  become  developed  in  cyst-like  dilatations  of  the 
follicles,  in  which  the  secretion  accumulates  and  stagnates,  and  the  in- 
spissation of  the  contents  of  encysted  tumors  of  new  formation,  applies 
here  in  its  most  extended  sense.  The  physical  and  chemical  properties 
are,  it  will  be  readily  conceived,  extremely  inconstant  and  variable. 

This  group  comprises  concretions  in  the  follicles  of  the  skin,  in  mu- 
cous follicles,  in  the  tonsils,  in  the  nasal  and  pharyngeal  cavities,  upon 
the  glans  and  prepuce,  and  certain  intestinal  concrements,  especially 
those  occurring  in  diverticula ;  finally,  the  inspissations  of  colloid,  and 
of  other  cyst-contents. 


CHAPTER  X. 

ANOMALIES  OF  CONTENTS. 

IN  this  chapter  we  have  to  treat  of : 

A.  Pneumatoses  and  Dropsy,  which  we  have  already  adverted  to  as 
non-organized  new  formations. 

B.  Foreign  substances  introduced  into  the  body. 

c.  Parasites,  that  is  animals,  and  vegetable  growths,  occurring  in 
and  upon  the  living  body.  We  give  them  a  place  in  this  chapter  be- 
cause, according  to  the  researches  of  modern  science  they  are  to  be 
numbered  amongst  the  things  that  are  received  into  the  organism  from 
without. 

A.    PNEUMATOSES  AND  DROPSY. 

1.  Pneumatoses, — the  accumulation  of  various  gases  has  been  ob- 
served as  emphysema,  both  within  textures,  and  more  particularly  in 
almost  every  cavity  of  the  body  and  of  its  organs.  The  scale  of  fre- 
quency varies,  indeed,  according  to  the  nature  of  the  gas,  and  to  its 
mode  of  origin.  There  are,  however,  organs  in  which  gas-accumula- 


PNEUMATOSES    AND    DROPSY,  255 

tions  of  every  kind  are  extremely  common ;  and  again,  others  in  which 
a  development  and  aceumulation  of  gas  are  under  all  circumstances 
very  rare. 

The  modes  in  which  gas-accumulations  originate  resolve  themselves 
generally,  into  the  following  : 

(a.)  The  gas  accumulated  in  the  texture  or  in  the  cavities  of  the  body 
or  of  organs,  is  atmospheric  air  which  has  penetrated  from  without. 
This  applies  to  most  kinds  of  emphysema,  and  of  gas-accumulations 
in  the  pleural  sac,  partly  to  those  in  the  stomach,  perhaps  also  to  the 
rare  instances  of  gaseous  collections  in  the  uterus,  and  in  the  urinary 
bladder ;  lastly,  to  the  presence  of  gas  in  the  blood  after  the  lesion  of 
veins,  particularly  those  of  the  neck.  Most  examples  of  interstitial  emphy- 
sema and  of  pneumothorax  are  the  result  of  lesions  of  continuity,  through 
either  wounds  or  ulceration  in  the  bronchial  passages  or  in  the  lungs. 

By  tarrying  in  preternatural  localities,  the  atmospheric  air  suffers  a 
change  similar  to  what  it  undergoes  in  the  lungs,  its  oxygen  becoming 
exchanged  for  carbonic  acid,  with  the  superaddition  of  aqueous  vapor. 

t)  The  gases  are  products  of  decomposition. — To  this  category  are 
reckoned,  besides  those  gas-accumulations  arising  out  of  putrefac- 
tion after  death, 

a.  Gas-development  out  of  the  blood-mass,  from  putrid  decomposition 
of  the  latter ;  out  of  blood  perishing  through  absolute  stasis ;  finally, 
out  of  decaying  normal  textures  or  morbid  products,  for  example, 
sloughing  cancers,  or  exudates  undergoing  decomposition. 

,3.  Gas-development  in  the  stomach  and  intestines,  the  details  of  which 
concern  special  anatomy. 

2.  Dropsy,  whereby  we  understand  genuine  serous  dropsy,  that  is,  a 
fluid  mostly  alkaline,  in  its  purity  colorless  and  limpid,  and  analogous  in 
the  quality  of  its  ingredients  to,  although  originally  thinner  than,  the 
serum  of  the  blood ;  a  fluid  which,  apart  from  the  accidental  admixture 
of  exudates,  pus-cells,  blood-globules,  epithelia  and  the  like,  contains 
nothing  beyond  unorganized  effusions  of  albumen,  pigments,  fats  (cho- 
lesterin),  and  salts.  Under  no  conditions  has  it  of  itself  alone  the  signi- 
ficance of  a  blastema. 

It  consists,  chemically  speaking,  of  water,  albumen,  fat  and  extractive 
matter,  and  of  salts,  the  chloride  of  sodium  preponderating  over  the  rest, 
namely,  the  carbonates  and  phosphates,  of  alkalies,  and  of  alkaline  earths. 
Generally  speaking,  its  proportion  of  water  is  greater  than  that  in  blood- 
scrum.  The  albumen  is  subject  to  the  greatest  fluctuation,  down  to  an 
infinitesimal  allotment. 

This  relation  is  liable  to  various  and  not  unfrequent  deviations. 

A  red  coloration  is  due  to  blood-pigment. 

A  yellow,  or  yellowish-green  coloration,  to  bile-pigment. 

A  whey-like  turbidness,  a  milky-white  appearance,  may  be  owing  to 
certain  of  the  admixtures  adverted  to,  such  as  epithelium,  but  especially 
fat,  and  to  an  albumen  precipitated  by  an  excess  of  water  [relatively  to 
the  saline  contents]. 

Sometimes  the  fluid  has  a  faint  acid  reaction. 

A  notable  proportion  of  albumen  renders  the  fluid  viscid,  adhesive, 
synovia-like. 


256  PNEUMATOSES    AND    DROPSY. 

This  albumen,  for  the  most  part,  shows  itself  to  be  pure ;  and  not  to 
differ  from  that  of  blood-serum  ;  or  else  it  exists,  as  albuminate  of  soda. 
It  occurs,  however,  in  certain  other  tolerably  well-known,  and  without 
doubt  in  many  other  as  yet  unknown  modifications. 

Occasionally  the  dropsical  fluid  contains  urea.  The  accumulation  of 
the  fluid  in  the  textures  constitutes  oedema,  of  which  species  of  infiltra- 
tion every  organ  may  become  the  seat.  Its  collection  in  cavities  of  the 
body,  or  of  organs,  constitutes  the  dropsies.  Moreover,  the  serous  effu- 
sion developed  beneath  the  vesicated  epidermis  in  erysipelas,  in  burns, 
and  through  the  agency  of  cantharides,  is  deserving  of  general  mention 
here. 

The  mode  of  origin  of  dropsy  varies  : 

(a.)  The  purest  dropsy  arises  from  retention  of  the  blood  in  the  veins 
through  mechanical  hindrance  to  the  circulation.  Its  extension  varies 
according  to  the  seat  of  the  obstruction,  being  considerable  in  proportion 
as  it  affects  the  centres  of  the  circulation.  It  is  in  all  probability  the 
veins,  even  the  larger  ones,  which,  in  a  dilated  and  thin-walled  condition, 
suffer  an  out-throwing  of  dropsical  fluid  to  take  place  from  the  blood. 
The  exudation  will  be  considerable,  proportionately  to  the  amount  of 
hydraemia — that  is,  of  the  serous  crasis — that  prevails. 

Dropsy  is,  without  doubt,  determined  by  the  lymphatics  in  a  similar  way. 

(b.)  Nor  is  there  any  doubt  that  serous  effusion  takes  place,  in  like 
manner,  from  the  capillary  vessels.  This  mode  of  occurrence  applies  to 
the  dropsy  resulting  from  general  debility ;  to  that  arising  in  palsied 
parts ;  to  that  referable  to  hydrsemia.  Again,  we  may  attribute  to  the 
same  source  that  acute  or  chronic  oedema  consequent  upon  mechanical 
capillary  hypersemia,  both  active  and  passive ;  and,  lastly,  that  oedema 
founded  in  a  slight  degree  of  stasis,  or  attendant  upon  consummate  in- 
flammation. Of  the  latter  description  are  those  outpourings  of  the 
blood-serum  precursory  to  the  genuine  exudation  of  plasma  in  the  inflam- 
matory process ;  the  oedema  encircling  arese  of  inflammation ;  the 
aforesaid  serous  collections  beneath  the  epidermis,  in  erysipelas,  in 
burns,  &c. 

(c.)  In  fine,  dropsical  effusions  are  brought  about  by  attenuation  of 
the  blood, — or  the  serous  crasis,  a  condition  frequently  combined  with 
the  aforesaid  causal  influences. 

The  consequences  of  serous  effusion  vary  greatly  according  to  the 
nature  of  the  organs  or  textures  concerned,  to  the  extent  of  the  accumu- 
lations, to  the  acute  or  chronic  form  of  their  occurrence,  and  to  their 
duration.  The  relation  of  the  textures  generally  is  of  much  interest. 
In  acute  dropsy  the  textures  are  in  various  degrees  congested,  reddened, 
and  withal — more  especially  the  lung  texture — lax,  easily  torn ; — very 
delicate  textures,  for  example,  that  of  the  brain,  softened  and  destroyed. 
In  chronic,  enduring  dropsy,  on  the  contrary,  they  are  discolored,  pallid, 
bloated  with  imbibed  serum.  Smooth  membranes  become  turbid  and  dull, 
the  contractile  fibre  paralyzed. 

Dropsical  fluid  is  either  wholly  or  partially  re-absorbed,  or  continues 
unchanged.  In  the  second  case,  the  watery  part  being  first  of  nil 
absorbed,  it  becomes  concentrated  to  an  albumen,  a  synovia,  or  a  thin 
jelly-like  mass. 


PARASITES.  257 

In  what  manner  the  various  oedemata  and  dropsies  may  become  peri- 
lous, and  eventually  prove  fatal,  is  sufficiently  evident. 

B.  FOREIGN  BODIES. 

Inanimate  foreign  bodies  are  not  unfrequently  met  with  in  the 
organism. 

They  are  introduced  accidentally  or  designedly,  either  through  the 
natural  orifices,  as  the  mouth,  the  anus,  the  orifices  of  the  urethra  and 
vagina,  the  ears,  the  nostrils ;  or  else  by  violence,  at  various  parts,  as 
by  means  of  projectiles,  of  puncture,  of  a  blow,  of  cautery,  &c. 

They  include  things  the  most  dissimilar,  as  fish-  and  other  bones,  fruit 
stones  and  seeds,  coins,  rings,  natural  and  artificial  teeth,  straw,  ears  of 
grain,  pencils,  needles,  tobacco-pipe  fragments,  dagger  and  sword  points, 
knives,  gunshot  materials  of  all  kinds,  fragments  of  dress,  of  glass, 
pigments. 

These  foreign  bodies  are  often  got  rid  of,  sooner  or  later,  through  the 
natural  channels.  Occasionally,  however,  they  abide  long — it  may  be 
for  life — without  occasioning  serious  annoyance,  and  are  afterwards 
found  to  have  become  isolated  within  a  callous  exudate-capsule. 

In  other  cases,  they  give  rise  to  various,  more  or  less  perilous  symp- 
toms, and  not  unfrequently  prove  fatal.  Thus,  they  may  act  as  plugs, 
or  injure  in  many  other  ways  every  variety  of  organ.  Again,  they  may 
induce  and  sustain  inflammation  and  ulceration  to  the  exhausting  point. 

A  certain  interest  attaches  to  the  migrations  of  foreign  bodies,  as  now 
and  then  witnessed  in  the  case  of  needles,  grain-ears,  and  bullets ;  these 
being,  after  a  longer  or  shorter  interval,  discovered  or,  perhaps,  sponta- 
neously ejected  through  suppuration,  at  parts  of  the  body  remote  from 
the  point  of  their  introduction.  These  migrations  are  sometimes  the 
result  of  gravitation,  as  in  the  case  of  bullets.  At  other  times  they  are 
obviously  quite  independent  of  this  motive  power. 

c.  PARASITES. 

Under  this  generic  term  we  comprehend  such  formations,  infesting  the 
organism  both  within  and  without,  as  represent  independent  entities,, 
either  from  the  vegetable  or  animal  kingdom.  Their  investigation  belongs 
to  pathological  anatomy  in  general,  but  especially  so,  inasmuch  as  the 
presence  of  parasites  not  only  implies  previous,  but  also  engenders  newr 
morbid  conditions.  Moreover,  they  merit  a  place  in  this  chapter  because- 
it  is  daily  becoming  more  clear  that  they  are  not  the  production  of  a 
generatio  cequivoca  out  of  diseased  organic  matter,  but  that  they  enter 
into  the  organism  from  without,  and  find  there  a  soil  appropriate  for 
their  subsistence  and  growth. 

Parasites  are  introduced  into  the  organism  either  as  seeds,  as  ova,  or 
in  a  more  advanced  condition, — to  germinate,  become  developed,  or  grow, 
in  or  upon  the  organism.  Nor  is  it  less  evident  that  certain  pathological 
states  determine  a  disposition,  not  exactly  to  the  generation,  but  to  the 
evolution  and  redundant  growth  of  parasites,  for  which  they  furnish  the 
necessary  conditions.  Thus,  parasite  plants  (fungi)  readily  and  com- 

VOL.  i.  17 


258  PARASITES. 

monly  germinate  in  particular  exudates  upon  mucous  membranes,  whilst 
upon  normal  mucous  membranes  their  sporules  remain  undeveloped. 
Parasites  become  pernicious  in  various  ways. 

I.  PARASITE  PLANTS  (Epiphytes,  Entophytes). 

These  all  belong  to  the  lowest  forms  of  plants,  the  fungi,  and  unless  col- 
lected together  in  redundant  growth,  they  are  too  minute  to  be  cognizable 
with  the  naked  eye. 

Respecting  their  origin  by  propagation  through  sprouts  and  sporules 
hardly  a  doubt  can  exist,  and  as  little  as  to  their  translation  upon  and 
into  the  organism ;  although  only  in  a  few  instances  has  it  been  possible 
to  certify  this  by  direct  evidence. 

It  is  obvious  that  certain  conditions  are  requisite  for  the  harboring 
and  the  evolution  of  these  germs.  This  often  manifestly  consists  in 
pathological  conditions,  and,  at  the  same  time,  often  in  processes  of  de- 
composition (fermentation,  putrefaction).  In  the  great  majority  of  in- 
stances, however,  we  are  in  the  dark  concerning  those  conditions,  and 
the  success  of  our  experiments  is  dependent  upon  chance.  The  former 
contingency  is  exemplified  in  fungi  upon  muco-membranous  exudates, 
sloughs,  and  upon  mortifying  patches  of  the  common  integument. 

The  relation  of  the  vegetable  parasite  to  the  concurrent  morbid  condi- 
tion varies.  The  latter  sometimes  stands*  in  that  of  a  pre-existent  state, 
favorable  to  the  development  and  multiplication  of  the  fungi ;  at  other 
times  the  parasite,  harbored  through  influences  unexplained,  may  become 
the  cause  of  textural  disease ;  for  example,  inflammation,  suppuration, 
decadence  and  loss  of  hair,  &c. 

Herewith,  the  injury  they  inflict  upon  the  organism  terminates.  Still 
they  may,  where  they  vegetate  extensively,  become  further  mischievous 
by  increasing  or  specifically  modifying  some  process  of  decomposition. 
We  may  instance  the  fungi  of  aphthae. 

If  we  except  the  torula  cerevisise  in  the  contents  of  the  stomach  and 
intestines,  the  torula  of  diabetic  urine,  and  perhaps,  Goodsir's  sarcina 
ventriculi  (possibly  an  infusorium1),  parasitic  plants,  in  man,  affect  the 
common  integuments  and  mucous  membranes  only. 

With  their  buds  shooting  out  into  more  or  fewer  long,  linked, 
branched  threads,  they  present  the  form  of  the  thread-fungus. 

1.    FUNGI   UPON  AND  WITHIN  THE   COMMON   INTEGUMENT. 

The  most  important  are  : — 

(a.)  The  mycoderma  in  tinea  favosa  (Schonlein,  Gruby).  Shut  up  in 
splitting  capsules,  it  constitutes  the  skin-imbedded  favus.  These  fungi, 
like  the  torula  cerevisiae,  present  in  their  most  simple  form,  roundish  or 
oval  cells,  and  these  put  forth  buds,  which  shoot  out  into  simple  or 
branched  threads.  The  favus-i\mg\\$>  belongs  to  the  genus  Oidium 
(Linck),  and  according  to  Muller  greatly  resembles  the  oidium  aureum 
of  wood.  Or,  according  to  Corda,  it  may,  together  with  all  thread-fun- 
guses, which  fructify  by  simple  separation  of  their  links,  and  in  which 
every  link  may  become  a  spore,  be  taken,  along  with  yeast  funguses,  into 
the  great  genus  Torula. 

1  [It  is  now,  however,  pretty  generally  admitted  to  be  an  alga. — ED.] 


PARASITE    ANIMALS.  259 

There  is  as  yet  no  certainty  as  to  the  part  played  by  these  thread- 
fimguses.  Attempts  at  inoculation  have  hitherto  failed,  with  the  excep- 
tion of  one  experiment  made  by  Remak. 

(b.)  Fungi  in  the  root-sheath  of  the  hair  in  sycosis  [mentagra,  Gruby]. 
They  collect  around  the  hair  itself  within  the  root-sheath,  and  are 
marked  by  redundant  spore-formation.  The  spores  are  spherical  and 
the  thallus-threads  frequently  contain  in  their  interior  little  granules. 

(c.)  Fungi  in  the  interior  of  the  hair-roots  [Gruby].  In  alopecia  cir- 
cumscripta,  areata  [porrigo  decalvans],  the  falling  out  of  the  hair  is 
caused  by  a  thread-fungus,  called  by  Gruby,  on  account  of  the  minute- 
ness of  its  spores,  microsporum. 

(d.)  In  plica  Polonica,  Giinsburg  has  detected,  in  the  hair-bulbs,  a 
fungus  which  differs  from  that  of  favus. 

(e.)  In  Pityriasis  versicolor,  Eichstedt  has  discovered  a  thread-fungus. 

Fuchs,  Klenke,  Helmbrecht,  have  observed  a  fungus  formation  in  lepra 
alphoides,  and  inoculated  it  with  success. 

Langenbeck  met  with  a  fungus  in  crusta  serpiginosa. 

Finally,  the  mould  formations  upon  sloughing  ulcers,  and  in  senile 
gangrene,  come  under  this  head.  They  are  both  frequent  and  copious. 

2.    FUNGI   UPON   MUCOUS   MEMBRANES. 

These  are  very  often  found  upon  the  mucous  membrane  of  the  mouth, 
the  pharynx,  the  oesophagus,  the  intestinal  canal,  that  is  to  say  in 
fibrino-croupous,  and  especially  in  corroding,  aphthous  exudates. 
Aphthae  and  diphtheritis  of  the  mouth  and  throat ;  croupous  exudates  in 
the  same  localities,  in  florid  phthisis ;  croupous  exudates  in  the  larynx, 
oesophagus,  &c.,  in  the  sequel  to  typhus. 

They  are  assuredly  not  the  morbific  agent.  The  croupous  exudates 
upon  which  they  vegetate  are  cognizable  to  the  naked  eye,  for  those 
familiar  with  the  subject,  by  a  peculiar  character,  consisting  in  a  viscid, 
curdlike  turgescence,  dingy  yellow  or  tawny  discoloration,  and  a  broken 
or  jagged  aspect. 

The  fungi  resemble  those  of  favus.  The  thallus-threads  are,  however, 
mostly  much  longer,  more  slender,  and  have  frequently  at  their  free  ex- 
tremity protuberances  replete  with  minute  granules  (spores).  They 
often  form  very  compact,  felt-like  tissues. 

Amongst  these  funguses  are,  no  doubt,  to  be  counted  the  fungus 
Noma,  of  Klenke ;  those  found  by  Bennett  in  the  sputa  and  lungs,  in  a 
case  of  pneumo-thorax,  as  also  in  the  black  sordes  upon  the  teeth,  in 
typhous  patients  ;  again,  those  seen  upon  so-called  typhus-ulcers  in  the 
intestines ;  lastly,  the  mould  such  as  we  ourselves  once  observed  upon  an 
old  blood-clot,  unattached  within  a  bronchial  sac. 

II.  PARASITE  ANIMALS  (Siebold). 

Parasite  animals  are  divisible,  although  not  strictly  so,  into  ecto-para- 
sites  (epizoa),  and  into  ento-parasites  (entozoa).  The  former  infest  the 
surface  of  the  body,  the  latter  its  different  cavities  and  parenchymata. 

Some  of  them  are  parasitic  during  their  entire  existence ;  others  only 


260  INFUSORIA.  —  INSECTS. 

at  certain  periods  of  it.  For  this  purpose  the  latter  migrate,  and  enter 
into  various  metamorphoses. 

Some  of  them  inhabit  exclusively  certain  definite  parts  of  the  body, 
both  cavities  and  parenchymata,  others  on  the  contrary  occur  in  various 
regions  of  the  body,  and  in  great  numbers  all  at  once.  All  this  is  con- 
tingent upon  their  habitudes,  and  perhaps  still  more  upon  the  mode  in 
which  they  obtain  access  to  their  place  of  abode. 

With  regard  to  the  difficult  question  of  their  origin  and  propagation, 
modern  researches  in  the  least  promising  domain,  namely,  of  the  helmin- 
thes,  have  pretty  well  succeeded  in  subverting  the  older  doctrine  con- 
cerning the  generation  of  parasites,  and  their  relation  to  the  animals 
which  they  infest. 

They  get  introduced  into  the  organism  as  ova,  as  larvae,  or  even  as 
developed  creatures  ;  and  wherever  they  meet  with  a  nidus  congenial  to 
their  nature,  live  and  thrive  upon  it.  For  this  habitation  to  last,  how- 
ever, a  peculiar  disposition  on  the  part  of  the  subject  is  no  doubt  indis- 
pensable. In  the  different  parasites  this  sort  of  predisposition  differs 
materially.  Much  is  assuredly  not  required  to  incur  a  visitation  of 
ascarides.  On  the  other  hand,  notwithstanding  the  extensive  dissemina- 
tion of  the  ova  of  the  helminthes,  the  disproportionately  small  number 
of  persons  affected  with  worms ;  the  circumstance  that,  under  certain 
conditions  (for  example,  disease),  worms  for  the  most  part,  if  not  alto- 
gether, abandon  the  individual  they  had  infested ;  and  lastly,  the  fact 
that  different  kinds  of  worms  are  proper  to  different  animals ;  testify  to 
the  necessity  of  the  peculiar  disposition  adverted  to,  existing  in  persons 
affected  with  worms. 

1.    INFUSORIA. 

The  most  frequent  are  the  vibriones,  in  purulent  and  other  protein- 
fluids  in  the  progress  of  decomposition.  Donnd  has  detected  a  vibrio  in 
the  pus  of  chancre,  and  rated  it  beyond  its  worth. 

In  pus,  the  vorticella,  and  also  the  colpoda  cucullulus  (Yogel)  occur. 

The  trichomonas  vaginalis,  detecting  by  Donne  in  the  vaginal  mucus 
of  syphilitic  females,  is  probably  not  an  infusorium,  but  a  misshapen 
ciliary  cell  from  the  uterus  or  the  tubes. 

Lastly,  we  have  to  cite  the  hcematozoa  occurring  in  the  blood  ;  if  they 
be  not  rather  the  embryones  of  worms,  which  is  probably  the  case  with 
many  of  them. 

2.  INSECTS. 

Besides  the  various  flies  which  infest  putrid  ulcers  with  their  ova  and 
maggots,  and  the  exotic  [still  problematic]  oestrus  hominis,  we  have  the 
flea,  the  lice,  and  the  bug. 

(a.)  Pulex  irritans,  the  common  flea. 

(b.)  Pulex  penetrans,  the  sandflea,  common  in  the  West  Indies  and 
in  South  America.  The  impregnated  female  burrows  into  the  skin, 
especially  beneath  the  toe  nails,  where  the  brood  gives  rise  to  malignant 
sores. 


INTESTINAL    WORMS.  261 

Of  lice  there  are — 

(a.)  Pediculus  capitis,  the  head-louse. 

(b.)  Pediculus  pubis,  the  crab-louse,  infesting,  the  scalp  excepted, 
every  hairy  part,  and  penetrating  the  skin  with  its  head. 

(c.)  Pediculus  vestimenti,  the  clothes-louse,  infesting  parts  of  the 
body  devoid  of  hair,  and  uncleanly  vestments. 

(d.)  Pediculus  tabescentium,  the  louse  of  wasting  disease,  in  which 
it  occurs  in  great  multitudes.  The  notion,  however,  that  there  is  a 
disease  in  which  lice  are  generated  beneath  the  skin,  is  without  doubt 
fallacious. 

Of  bugs,  we  have  only  to  mention  the  ordinary  bed-bug,  cimex  lectu- 
larius. 

3.    ARACHXIDA,  ACARINA. 

(a.)  The  itch-mite,  acarus  scabiei,  sarcoptes  hominis,  punctiform, 
from  a  quarter  to  half  a  millimetre  long,  ovoid,  garnished  with  trans- 
verse, bandlike,  dorsal  striae,  and  with  central,  acuminate  warts ;  ante- 
riorly a  bristled  proboscis,  prolonged  inferiorly  to  a  band  upon  the 
thorax ;  four  bristly  fore-feet  terminating  in  disk-plate,  whilst  the  four 
hind-feet  taper  into  lengthy  bristles. 

,  It  burrows  in  the  epidermis,  often  boring  beneath  it  a  canal  several 
lines  long,  at  the  termination  of  which  the  acarus  is,  on  a  narrow 
inspection,  discoverable  as  a  minute  whitish  speck,  marked  with  a  brown 
point.  When  the  said  canals  penetrate  to  the  cutis,  they  engender  the 
itch-vesicles  and  pustules. 

Researches  into  the  natural  history  of  this  mite,  together  with  the 
results  of  extended  experience,  prove  beyond  a  doubt  its  relation  to  itch 
as  its  sole  cause. 

The  follicle  mite,  acarus  commedonum  sive  folliculorum,  an  elon- 
gated acarus,  from  one-fifth  to  one-third  of  a  millimetre  long,  and 
about  one-twentieth  broad,  the  head  having  two  lateral  antennae  and  an 
intermediate  proboscis.  The  head  passes  immediately  into  the  anterior 
part  of  the  body,  which  occupies  about  one-fourth  of  the  entire  mite. 
From  it  project  four  pair  of  very  short,  thick,  conoid,  three-jointed 
feet,  each  furnished  with  three  toes.  The  anterior  body  passes  without 
break  into  the  posterior,  which  gradually  tapers,  but  is  rounded  off  at 
the  extremity,  is  transversely  striated,  and  contains  a  finely  granular, 
brownish  mass. 

It  inhabits  singly  or  numerously  the  hair  sacs  and  sebaceous  follicles 
on  various  parts  of  the  person.  Amongst  other  anomalies,  it  occa- 
sionally displays  only  six  feet,  which  no  doubt  implies  an  earlier  state 
of  its  development.  Its  presence  is  probably  often  of  little  moment. 
Occasionally,  however,  it  may,  by  stimulating  the  secretion,  engender 
commedones,  or  set  up  inflammation,  and  thus  give  rise  to  the  acne 
pustule. 

4.    INTESTINAL  WORMS. — HELMINTHES. — ENTOZOA. 

Restricting  ourselves  here  to  the  consideration  of  such  as  are  peculiar 
to  man,  we  would  preface  our  special  description  of  them  with  the  fol- 
lowing general  remarks : 


262  INTESTINAL  WORMS. 

(a.)  Intestinal  worms,  in  their  consummated  development,  are  all 
provided  with  organs  of  generation.  Those  in  which  the  latter  have 
not  been  demonstrated,  are  propagated  by  buds  or  by  offshoots,  if  they 
be  not  imperfect,  that  is,  either  larvae  or  diseased  animals.  As  opposed 
to  the  doctrine  of  equivocal  generation,  these  facts  are  important,  if  we 
consider : 

(b.)  The  migrations  and  the  attendant  metamorphoses  of  the  hel- 
minthes. 

The  migrations  of  the  helminthes  consist,  first  in  the  search  for  a 
suitable  animal  to  inhabit,  and  in  introducing  themselves  into  it,  when 
found,  through  channels  formerly  unthought  of.  Secondly,  they  consist 
in  abandoning  the  animal  dwelt  in,  for  the  purpose  of  casting  their  ova 
under  favorable  conditions,  then  in  passing  through  one  of  their  meta- 
morphoses, and  lastly  in  searching  for  another  animal  for  their  habita- 
tion. They  pass,  under  various  phases  of  development,  for  the  most 
part  through  natural  orifices  of  the  body,  more  especially  into  and  out 
of  the  intestinal  canal.  Their  occurrence,  however,  even  in  the  paren- 
chymata,  is  intelligible  upon  grounds  of  direct  experience.  As  illus- 
trative of  this,  the  larvae  of  cercarioid  trematoda,  and  of  the  tetrar- 
hynchi,  have  been  observed  to  migrate  through  the  parenchymata  of 
mollusca  and  fishes.  It  is  also  deserving  of  notice,  in  this  place,  that 
helminthes  may  reach,  and  settle  in  any  parenchyma  through  the  circu- 
lating channels,  probably  by  boring  for  themselves  a  passage  into  the 
bloodvessels  of  the  intestinal  canal.  This  applies  to  the  nematoid, 
thread-like  animals  found  by  Valentin,  Vogt,  Gruby,  Ecker,  and  others, 
in  the  blood  of  frogs,  dogs,  and  ravens,  and  probably  representing  the 
embryones  of  helminthes. 

This  migration  of  the  helminthes  may  involve  frequent  aberrations, 
and  these  in  their  turn  many  phenomena,  which  an  extended  inquiry 
will  perhaps  correctly  set  down  to  a  morbid  condition.  We  refer  more 
particularly  to  the  encysting,  the  atrophy,  and  the  deformity  of  certain 
helminthes ;  amongst  others,  of  the  trichina  spiralis,  and  the  taenioid 
cystica. 

(c.)  The  metamorphoses  of  the  helminthes,  coincident  with  their 
migrations,  are  of  the  greatest  interest.  They  constitute  a  circle  of 
generations,  which  Steenstrupp,  following  up  the  investigations  of  other 
naturalists,  has  pointed  out  in  the  trematoda  (as  in  the  medusae,  bulb- 
polypi,  and  salpse).  A  parent  animal  produces  a  brood  altogether 
dissimilar  to  itself,  nor  identified  with  it  until  after  three  or  four  gene- 
rations. These  intervening  generations  of  larvae — these  pro-nutrices 
and  nutrices — form  without  sexual  mediation,  and  are  the  source  of  the 
numerous  fallacies  taught  by  the  older  helminthologists. 

(d.)  All  this  accords  perfectly  well  with  the  strict  limitation  of 
certain  worms  to  particular  countries.  The  most  striking  example  is 
afforded  in  those  two  riband-worms,  the  botryocephalus  latus,  of  Russia, 
Poland,  Prussia  up  to  the  Vistula,  and  Switzerland;  and  the  taenia 
solium  of  the  remainder  of  Europe. 

(e.)  On  the  other  side,  the  doctrine  of  the  origin  of  the  helminthes 
out  of  intestinal  mucus  and  the  like,  has  not  a  single  point  of  real  evi- 
dence in  its  favor.  A  disposition  to  worms  exists  only  in  so  far  as  an 


NEMATOIDEA.  263 

organism  abnormally  nourished  offers  to  helminthes,  introduced  into  it 
from  without,  a  nidus  well  adapted  for  their  development. 
In  mankind  the  following  helminthes  occur  : — 

NEMATOIDEA,    ROUND   WORMS,    THREAD   WORMS. 

Filar ia  medinensis,  the  thread  or  Guinea-worm,  of  about  the  thick- 
ness of  packthread,  whitish,  from  half  a  foot  to  several  feet  long,  j^t  the 
broader  end  obtunded,  terminating  behind  in  a  pointed  curve.  Peculiar 
to  tropics  of  the  Old  World,  but  especially  to  Guinea ;  inhabits  the  sub- 
cutaneous areolar  tissue,  especially  of  the  lower  extremities,  but  occa- 
sionally also  of  the  scrotum,  the  trunk,  and  the  throat.  Having  spent 
its  earlier  period  out  of  the  body,  it  burrows  beneath  the  skin,  where  it 
tarries  in  the  areolar  tissue  for  a  considerable  time  (several  months), 
after  which  it  again  perforates  the  skin  from  within,  in  order  to  dis- 
burden itself  of  its  offspring,  or  in  order,  it  may  be,  to  migrate  for  this 
purpose  altogether.  These  proceedings  are  attended  with  inflammation 
and  ulceration,  and  great  caution  is  recommended,  in  any  attempt  to 
extract  the  worm,  to  avoid  tearing  it ;  either  the  elapsing  brood  or  other 
contents  of  the  worm,  having  an  erosive  property  which  tends  to  aggra- 
vate the  said  processes.  It  would  seem  that,  as  yet,  none  but  females 
have  been  observed.  Accordingly  these  must  have  introduced  them- 
selves in  the  impregnated  state. 

Trichoceplialus  dispar,  the  hairhead  or  whip- worm ;  filiform ;  the 
anterior  part  hair-like,  the  posterior  part  considerably  thicker ;  from 
one  and  a  half  to  two  inches  long ;  of  distinct  sexes.  The  male  is,  at 
its  posterior  part,  spirally  convoluted,  and  its  penis  contained  in  an 
elongated,  funnel-shaped,  violet-colored  sheath.  The  posterior  part  of 
the  female  is  not  spiral. 

It  infests  the  caecum,  singly,  and  also  frequently  in  multitudes  [espe- 
cially, it  is  true,  in  the  dead  bodies  of  persons  who  have  died  of  pro- 
tracted typhus  or  similar  diseases],  without  occasioning  any  extraordi- 
nary symptoms.  The  females  are  loaded  with  ova,  which  are,  however, 
not  developed  in  this  locality. 

Ascaris  lumbricoides,  the  cylinder  worm,  a  widely  disseminated  intes- 
tinal worm,  from  five  to  twelve  inches  in  length,  cylinder-shaped,  taper- 
ing towards  both  extremities,  especially  towards  the  anterior;  having 
four  longitudinal  striae,  two  of  which  are  more  strongly  pronounced ; 
densely  marked  with  transverse  striae :  semi-diaphanous,  so  that  the 
intestinal  canal  and  the  organs  of  reproduction  are  transpicuous.  The 
head,  divided  from  the  body  by  an  annular  groove,  displays  three  little 
nodules,  or  rather  valves,  which  encircle  the  mouth. .  The  caudal  extre- 
mity, especially  in  the  male,  is  incurvate.  Sexes  distinct,  the  male 
being  smaller  and  narrower,  and  having  at  the  caudal  extremity  a  thin, 
capillary,  sometimes  double  penis.  The  female  is  larger,  and  exhibits 
at  its  upper  third  a  fissure  from  six  to  eight  millimetres  long,  as  the 
orifice  to  the  organs  of  generation,  which  contain  ovaries  and  oviducts 
of  enormous  length. 

It  infests  the  ileum,  often  in  extraordinary  number,  in  groups  and  con- 
glomerate masses.  A  brood  is  never  met  with ;  the  ova,  therefore,  be- 


264  NEMATOIDEA. 

come  hatched  extraneously  to  the  human  body,  to  remigrate  thither  after- 
wards, as  the  living  brood.  It  gives  rise  to  the  well-known  worm  symp- 
toms. The  perforation  of  the  intestine,  however  [migration  extraneous 
to  the  intestinal  membranes],  and  its  sequelse  are,  to  say  the  least,  ex- 
tremely rare. 

Oxyuris  vermicularis  (the  Ascaris  vermicularis  of  Rudolphi),  the 
hook-tail,  maw-worm ; — a  little,  thin,  white  worm.  Sexes  distinct.  The 
male  very  rare  and  small,  from  one  to  one  and  a-half  millimetres  long, 
with  spiral  convoluted  tail :  annulate  ;  with  a  tail  terminating  in  a  fine 
transparent  point.  The  head  of  either  displays  a  transparent  swelling, 
which  under  the  microscope  appears  as  a  wing-like  membrane. 

It  inhabits  the  colon  and  especially  the  rectum,  occasioning  both  here 
and  in  the  vagina,  into  which  it  creeps,  an  intolerable  itching.  As  it 
is  never  accompanied  by  a  brood,  it  probably  migrates  as  the  impreg- 
nated female. 

Strongylus  gig  as  [Pallisadenwurm].  Giant  strongle ;  a  very  large, 
cylindrical  worm,\of  from  five  inches  to  three  feet  long,  and  from  two 
to  six  lines  in  thickness ;  when  recent,  of  a  fine  red  color.  Sexes  dis- 
tinct ;  the  male  smaller,  more  tapering  towards  both  ends ;  annulate, 
with  shallow,  longitudinal  grooves  ;  head  obtuse,  with  six  papillae  ;  at 
the  tail  extremity,  a  funnel-shaped  pouch,  out  of  which  protrudes  a  very 
thin  penis.  The  female,  larger,  with  o*btused  caudal  extremity,  and 
near  it  the  vulva. 

Inhabits  the  kidneys ;  is  rare  both  in  man  and  in  brutes  [found  in  the 
dog,  the  wolf,  the  marten,  the  horse,  &c.] 

To  these  may  be  added  the  following  nematoda  and  nematoid  pseudo- 
parasites,  some  of  them  being  very  rare,  or  even  but  once  met  with. 

^\\.Q  filaria  broncliialis.  \_Hamidaria  lympliatica,  Treutler — H.  sub- 
compressa  B.,  once  seen  by  Treutler  in  a  degenerated  bronchial  gland 
in  the  human  subject.]  Filaria  oculi  humani  [in  the  liquor  Morgagni 
and  in  the  cataractous  lens,  Gescheidt,  Nordmann].  The  filaria  in  the 
blood  [Klenke] ;  the  ancliylostoma  duodenale  [Dubini,  in  the  duode- 
num] ;  the  spiroptera  hominis  [Barnett,  in  the  urine]  ;  the  dactylius 
aculeatus  [Curling,  in  the  urine].  Finally  the  encysted  nematoda. 

Trichina  spiralis,  an  incarcerated  worm,  which  one  might  be  tempted 
to  class  intermediately  between  the  nematoda  and  the  cystica,  were  it 
not  extremely  probable  that  it  is  only  a  strayed  nematodon  which,  with- 
out coming  to  maturity,  encysts  itself,  perishes,  and  cretifies  within  a 
second  cyst  thrown  out  from  the  textures. 

The  worm  is  enclosed  within  a  double  cyst,  an  external  one,  mostly 
lemon-shaped,  and  an  inner,  oval  one ;  the  space  of  the  first,  at  its  two 
ends,  being  filled  up  with  very  fine  dark  granules.  Both  consist  of  a 
homogeneous,  faintly  granular  structure  ;  the  former  being  about  one 
fiftieth  of  an  inch  long,  and  one  ninety-fifth  broad,  the  latter  one  seventy- 
seventh  long.  In  the  inner  cyst,  amidst  a  more  or  less  granular,  viscid, 
transparent  fluid,  lies  the  worm,  perfectly  free,  and  generally  rolled  up 
in  two  and  a  half  spiral  convolutions.  When  extended  it  is  from  one 
twenty-fifth  to  one  thirtieth  of  an  inch  long,  and  about  one  six-hundredth 
broad,  lumbricoid,  thread-like  at  both  extremities,  although  more  pointed 
at  the  one  than  at  the  other.  It  possesses  internally  a  winding  canal. 


CESTOIDEA.  265 

interpreted  as  intestine,  and  a  granular  organ,  the  designation  of  which, 
as  an  ovary,  is  without  doubt  erroneous. 

Occasionally  the  cyst  contains  two,  or  even  three,  worms. 

The  Trichina  spiralis  inhabits  the  voluntary  [striated]  muscles,  and 
always  in  vast  multitudes,  the  muscles  appearing  to  the  naked  eye 
studded  with  little  white  specks.  The  cysts  always  lie  with  their  long 
diameter  parallel  to  the  course  of  the  muscles.  [Hilton,  Owen,  Blizzard, 
Henle,  and  others.] 

TREMATODA,    SUCTION-WORMS. 

Especially  characterized  by  their  peregrinations  and  metamorphoses. 

Distoma  hepaticum,  and  D.  lanceolatum,  Liver-fluke  ;  flat,  melon- 
seed  or  lancet-shaped,  soft  worms,  of  a  yellowish-white  color,  with  two 
suction  pores ;  one  of  which  is  seated  at  the  head  extremity ;  the  other, 
which  terminates  cgecally,  at  the  belly.  Between  the  two  is  the  sexual 
orifice.  They  are  hermaphrodites. 

The  Distoma  hepaticum  is  the  larger,  being  from  four  to  eight  or  to 
fourteen  lines  long,  and  from  one  and  a  half  to  six  broad,  with  a  branched 
intestinal  canal. 

The  Distoma  lanceolatum,  as  the  smaller,  is  from  two  to  four  lines 
long  and  about  one  broad.  Its  intestinal  canal  is  bifurcated. 

Both  infest  the  liver  of  the  herbivora,  rarely  of  man.  The  D.  lanceola- 
tum has  only  once  been  met  with  in  the  latter.  In  brutes  they  occur  in 
great  multitudes,  obstructing  and  dilating  the  gall-ducts. 

Distoma  oculi  liumani.  A  minute  distoma,  once  met  with  in  a  child 
between  the  cataractous  lens  and  its  capsule. 

Polystoma  pinguicola,  Hexathyridium  pinguicola  (Treutler).  An 
inch  long  and  from  two  to  three  lines  thick,  oval,  superiorly  convex,  in- 
feriorly  depressed  worm,  with  six  pores  at  its  head  extremity,  and  a 
larger  abdominal  aperture  anterior  to  the  tail.  Pound  once  by  Treutler 
in  the  fat  of  an  ovarian  fat-cyst. 

Polystoma  venarum,  HexatJiyridium  venarum  (Treutler),  probably  a 
pseudo-parasite. 

CESTOIDEA — TAPEWORMS. 

These  are  characterized  by  their  enduring  growth,  and  by  the  great 
length  to  which  they  attain.  They  consist  of  a  succession  of  linked 
joints,  of  which  the  fully  developed,  sexually  mature,  hindmost  ones  be- 
come cast  off  in  greater  or  lesser  series  ;  whilst  at  the  neck,  fresh  joints 
are  continually  being  reproduced.  As  in  these,  again,  a  brood  is  rarely 
seen  associated  with  the  old  individuals,  whilst  the  separated,  sexually 
mature  joints  so  frequently  become  ejected,  it  is  probable  that  the  em- 
bryones  become  developed  externally  to  the  animal  they  infest,  to  re-im- 
migrate subsequently. 

In  mankind  there  occur : 

The  Tcenia  solium,  T.  vulgaris,  T.  cucurbitina,  the  ordinary  tape- 
worm, long-jointed  tape-worm,  chain-worm ;  a  white,  or  yellowish-white 
worm,  twenty  feet  long  and  beyond  it,  anteriorly  thin,  roundish, — pos- 


266  VESICULAR    WORMS. 

teriorly  flat,  and  from  three  to  six  lines  broad, — -jointed.  The  joints  are 
flat,  square,  towards  the  distal  end  more  and  more  oblong-square,  re- 
sembling gourd-seeds  with  truncated  apices.  At  the  right  or  left  margin, 
often  alternately,  is  seen  a  wartlike  projection  marked  by  a  pore  with  a 
raised  brink.  This  is  the  orifice  of  the  sexual  organ,  which  represents  a 
cavity  dendritically  branched  throughout  the  joint.  The  head  constitutes 
at  the  very  thin  anterior  termination,  a  nodule-like  intumescence,  with 
four  lateral,  black  points  in  relief.  There  are  four  suction  pores ;  and, 
between  them  is  seated  upon  a  slightly  raised  circle  a  double  coronet  of 
booklets.  The  annulate  neck  is  studded  with  numerous  lime-corpuscles 
of  the  most  various  size  (vide  Cystica). 

Inhabits  the  small  intestine  in  man,  almost  in  all  districts,  except  where 
the  botryo-cephalus  occurs.  The  belief  that  it  only  occurs  singly  in  man 
is  quite  adverse  to  experience.  We  have  discovered  nine  of  them  in  the 
corpse  of  a  lad.  It  occasions  the  well-known  annoyances,  but  no  visible 
anatomical  mischief. 

Botryo-cephalus  latus,  tcenia  lata,  the  broad  or  broad-jointed  tape- 
worm, resembles  the  last  in  many  points,  equalling  it  in  length,  and 
being  in  like  manner  jointed.  Its  joints  are  usually  broader  than  those 
of  the  T.  solium ;  this  alone,  however,  cannot  pass  for  a  diagnostic 
mark.  The  wartlike  projections  are  not,  as  in  the  other  worm,  seated 
at  the  margin,  but  at  the  centre  of  tlie  ventral  surface.  Their  pore 
leads  to  a  branched  rosette-shaped,  sexual  organ.  The  head,  differing 
from  that  of  the  T.  solium,  exhibits  no  suction-pores,  but  two  longish 
grooves. 

Inhabits  the  small  intestine  in  man,  but  is  strictly  limited  to  Russia, 
Poland,  Prussia  [trans  Vistulam],  Switzerland,  and  to  the  South  of 
France.  If  it  occur  elsewhere  it  is  assuredly  imported  from  one  of 
those  countries. 

It  rarely  parts  with  single  joints  or  links,  but  usually  with  a  greater  or 
%esser  chain  of  them. 


CYSTICA. — VESICULAR   WORMS. 

In  the  formation  of  their  head,  these  resemble  tape-worms  to  such  a 
degree,  that  even  in  1836  Johannes  Muller  proposed  to  unite  them  in  a 
single  order,  with  two  subdivisions.  Light  has,  however,  been  since 
thrown  upon  the  subject,  which  warrants  us  in  going  a  step  further,  pro- 
nouncing these  cystica  with  tape-worm  heads  to  be  in  truth  nothing  more 
than  errant  cestoda,  which,  owing  to  their  deviations,  have  sickened,  de- 
clined, and  remained  sexless. 

The  lime  corpuscles  found  upon  them,  and  especially  upon  the  cysti- 
cercus,  are  the  same  as  those  occurring  upon  tape-worms.  They  have 
been  erroneously  held  to  be  ova,  and  in  reality  rather  represent  an  outer 
skeleton  formation.  These  cystica,  within  textures,  are  almost  always 
distinctly  encysted ;  that  is,  shut  up  within  a  capsule  effused  from  the 
textures.  In  free  spaces, — for  example  in  the  ventricles  of  the  brain, 
this  is  not  the  case.  This  adventitious  outer  cyst  is  not  to  be  confounded 
with  the  cyst  proper  to  the  animal  itself.  They  frequently  perish,  espe- 
cially through  inflammation  of  the  external  cyst,  being  either  mechani- 


VESICULAR    WORMS.  267 

cally  crushed  by,  or  corroded  and  destroyed  in,  the  product.  In  the 
sequel,  the  complicated  contents  of  the  outer  cyst,  after  having  suffered 
many  changes,  progressively  thicken,  and  eventually  cretify,  en  masse, 
within  the  shrivelled  capsule. 

The  unequivocal  proof  of  the  previous  existence  of  an  animal  in  such 
obliterated  cysts  is  furnished  by  ddbris  of  the  animal  cyst ;  by  booklets, 
from  the  coronet  of  booklets,  which  have  resisted  the  corrosive  agency ; 
and  lastly,  by  the  presence  of  the  lime  corpuscles  before  alluded  to. 

In  man  occur : 

The  cysticercus  cellulosus,  consisting  of  a  conical,  snow-white,  trans- 
versely rugous  body,  and  of  a  vesicle  which  constitutes  its  caudal  ex- 
tremity. The  vesicle  is  oval,  spherical  or  square, — in  muscles,  cylindrical, 
parallel  to  the  muscular  fibres, — and  of  the  size  of  a  pea  or  a  haricot 
bean, — in  rare  instances,  for  example,  in  the  ventricles  of  the  brain,  of 
a  hazel-nut.  When  the  animal  is  retracted  into  this  vesicle,  it  appears 
as  a  white,  spherical,  solid  body,  seated  somewhat  eccentrically  on  its 
inner  surface,  whilst  upon  the  vesicle  itself  is  observable,  externally,  a 
delicate  point-like  fold  or  depression  at  the  same  spot.  When  the  animal 
is  external  to  the  vesicle,  a  condition  easily  brought  about  by  puncturing 
the  vesicle,  and  pressing  the  hardish  spherical  body  between  the  finger 
and  thumb,  a  pore  becomes  perceptible  which  leads  to  the  interior  oT  the 
animal  pouch.  Taking  the  size  of  the  caudal  vesicle  at  the  ordinary 
one  of  a  pea,  the  animal  itself,  that  is  the  trunk,  would  about  equal  the 
diameter  of  the  vesicle,  both  together  measuring  from  six  to  twelve  lines 
in  length.  The  neck  is  short,  very  thin,  and,  like  the  body,  wrinkled. 
Upon  it  is  seated  the  largish,  bulb-shaped,  or  rhomboidal  head,  upon 
which  there  is  at  each  angle  a  circular  suction-cup  ;  and  midway  between 
these  a  proboscis,  cone-shaped  in  its  protruded  state,  with,  at  its  ex- 
tremity, a  coronet  of  booklets  consisting  of  a  double  row  [about  thirty- 
two  in  all],  which,  when  retracted,  pack  up  into  a  funnel-shaped  cup. 
The  two  circles  of  booklets  are  identical  in  shape ;  those  of  the  outer 
circle  are  however  much  smaller  than  the  others,  whilst  both  are  so  dis- 
posed that  the  larger  and  smaller  booklets  alternate  with  each  other. 

The  above-mentioned  transversely  wrinkled,  anterior  portion  of  the 
creature  appears  as  an  almost  structureless,  feebly  striated  membrane, 
to  which  a  profusion  of  fine,  black-contoured  molecule  adheres.  It  is, 
moreover,  studded  with  a  multitude  of  roundish  or  oval,  whitish,  smooth, 
sharply  contoured,  shining,  lesser  or  bigger  corpuscles,  of  from  one- 
eightieth  to  one-thirtieth  of  a  millimetre  in  diameter.  They  are  most 
numerous  about  the  middle  part ;  near  the  neck  and  head  their  number 
greatly  diminishes,  whilst,  close  to  the  caudal  vesicle,  they  suddenly  and 
entirely  disappear.  They  lie  superimposed  in  several  layers,  those  of 
the  outer  stratum  being  only  loosely  adherent  to  the  animal,  so  that  they 
may  be  very  easily  scraped  away.  Treated  with  hydrochloric  or  with 
acetic  acid,  they  dissolve  under  the  copious  development  of  carbonic  acid, 
leaving  an  organic  base-substance  behind.  In  the  solution,  oxalic  and 
sulphuric  acids  create  a  precipitate. 

The  caudal  vesicle  consists  of  the  same  homogeneous,  indeterminate, 
granulated  mass,  besprinkled  with  countless  small  and  larger  fat-molecules. 
The  contents  of  the  caudal  vesicle  consist  of  a  watery,  neutral  fluid, 
holding  but  a  scanty  portion  of  albumen. 


268  VESICULAR    WORMS. 

Wherever  the  cysticercus  occurs  in  textures,  it  is  inclosed  within  a 
second  cyst  of  fibrous  texture.  When  magnified  it  appears  as  a  deli- 
cately-fibred membrane,  permeated  by  delicate  blood-vessels,  and  easily 
rendered  transparent  by  acetic  acid.  Where  the  cysticercus  occurs  free 
within  a  cavity,  as  within  the  ventricles  of  the  brain,  it  is  uninvested, 
showing  the  outer  cyst,  in  other  localities,  to  be  adventitious. 

When  the  creature  perishes,  as  frequently  happens  from  disease  of  the 
outer  cyst,  the  caudal  vesicle  becomes  semi-opaque,  collapsed,  its  contents 
turbid,  displaying  the  said  lime-corpuscles  and  booklets,  which,  together 
with  a  granulate  mass,  are  found  floating  in  its  fluid.  The  entire  crea- 
ture softens  and  liquefies,  afterwards  condenses,  and  eventually  settles 
into  a  cretaceous  concrement.  Meanwhile  the  outer  cyst  shrivels  and 
dwindles  into  a  thick-membraned  capsule,  for  the  isolation  of  the  said 
concrement. 

The  cysticercus  cellulosus  occurs  in  the  brain,  in  the  striated  muscles, 
including  the  heart,  and  in  the  areolar  tissue.  It  also  occurs,  free, 
without  its  outer  envelope,  in  the  ventricles  of  the  brain,  and  in  the 
chambers  of  the  eye.  It  sometimes  occurs  in  the  muscles  and  brain 
simultaneously,  in  great  multitudes. 

Even  in  the  brain  it  is  usually  borne  imperceptibly.  When  present 
there  in  great  numbers,  however,  it  often  occasions  vertigo,  and  the  case 
has  happened  of  its  proving  fatal  by  setting  up  inflammation  in  its 
vicinity. 

Ecliinococcus  hominis  aceplialocystis  (Laennec).  The  relation  of  both 
to  each  other,  and  the  import  of  the  last-named  animal  in  particular,  will 
become  manifest  from  the  following  description  : 

(a.)  Echinococcus. — Within  a  sac  of  fibroid  texture  is  inclosed  a  soli- 
tary, independent,  thoroughly  distended  vesicle,  containing  a  limpid, 
serous  fluid ;  or  else  inclosing,  as  a  parent  vesicle,  other  similar  vesicles 
of  various  size,  in  various  numbers,  spherical  or  flattened  by  mutual  com- 
pression, either  floating  at  large  in  the  contained  fluid,  or  sessile  upon 
the  inner  membrane  of  the  said  parent.  Its  size  varies  from  that  of  a 
vesicle  just  cognizable,  and  as  big  as  a  poppy-  or  a  millet-seed,  to  the  magni- 
tude of  a  goose's  egg  and  more.  In  number  it  may  amount  to  hundreds, 
so  that  the  serous  contents  of  the  parent  vesicle  are  reduced  to  a  mini- 
mum. Generally  speaking,  the  lesser  filial  vesicles  are  sessile,  whilst  the 
larger  ones  are  free. 

In  very  voluminous  sacs  it  is  common  to  find  that  the  parent  vesicle 
appears  to  be  wanting.  Either  it  is  mixed  up  with  the  younger  vesicles, 
split  up,  collapsed  and  dissolved  into  scattered  shreds,  or  else  it  has  dis- 
appeared in  the  excessive  attenuation  consequent  upon  its  enlargement. 

In  their  unimpaired  vegetation,  these  vesicles  are  filled  to  distension, 
are  elastic,  and  impart  to  the  touch  a  sense  of  tremulous  fluctuation,  as 
does  the  parent  cyst  replete  with  them  [hydatid  tremulousness].  They 
consist  of  a  substance  resembling  coagulate  albumen,  separating  into 
several  layers,  partly  diaphanous,  partly  white  and  opaque,  frequently 
accumulated  in  the  inside  to  considerable  thickness,  and  into  gibbous 
projections.  Moreover,  they  contain  a  limpid  serosity  identical  with  the 
contents  of  the  parent  cyst.  When  the  vesicle  is  punctured,  this  fluid 
gushes  forth  in  a  column,  and  on  an  incision  being  made,  the  parietes  of 


VESICULAR    WORMS.  269 

the  vesicle  become  suddenly  inverted.  The  substance  of  the  latter  is  a 
stratified,  homogeneous,  very  fine-granular,  structureless  mass,  whilst 
their  contents  exhibit  a  few  lustrous  fat-drops,  some  scattered  or  agglo- 
merate, elementary  granules,  and  glebous  coagula. 

These  vesicles  occasionally  contain  others  similar,  of  a  third,  and  the 
latter  again  in  rare  instances  of  a  fourth  generation. 

On  a  narrower  inspection  of  the  inner  surface  of  these  vesicles,  we 
perceive  in  many  of  them,  a  whitish,  opaque,  gritty  efflorescence,  whilst 
with  the  aid  of  the  microscope  we  here  discover  densely-nestled  animal- 
cules, which  prove,  by  the  most  various  changes  of  shape,  that  they  long 
continue  to  live  on  in  the  dead  subject.  A  few  of  them  are  even  found 
free  in  the  above-mentioned  fluid. 

This  entozoon  is  from  one-ninth  to  one-third  of  a  millimetre  long,  and 
from  one-twelfth  to  one-fourth  of  a  millimetre  broad.  It  has  a  tsenioid 
head,  with  four  lateral  suction-pores,  and  a  proboscis  garnished  with  a 
double  coronet  of  booklets.  The  head  is  distinguished  from  the  thicker, 
spheroid  trunk,  by  an  annulate  indentation.  From  the  proboscis  a  longi- 
tudinal stria  tion  runs  to  the  posterior  part,  and,  commencing  from  these 
striae,  the  body  of  the  creature  is  transversely  striated.  The  posterior 
termination  is  a  transverse  cleft,  in  which  is  inserted  a  cordlike  forma- 
tion, by  whose  means  the  creature  maintains  its  seat  upon  the  vesicle. 
Between  the  striae  of  the  trunk  are  spherical  or  oval,  limelike  corpuscles, 
resembling  those  upon  the  cysticercus. 

In  its  developed  state  the  creature  appears  in  the  above  form.  It  is 
met  with,  however,  under  various  other  shapes.  Thus  it  appears  as  an 
elongated  sphere,  in  the  centre  of  which  the  coronet  of  booklets  appears 
perspicuous  when  the  head  is  retracted.  Or  it  assumes  the  shape  of  a 
heart,  or  of  a  pitcher,  or  even  of  a  horse-shoe. 

The  abode  of  this  echinococcus  in  mankind  is,  according  to  our  own 
experience,  invariably  internal  to,  and  never  external  to,  the  vesicles. 

(b.)  Acephalo-cyst.  Under  this  term  we  at  this  day  understand  no- 
thing beyond  those  vesicles  which  we  have  just  described  as  being  inha- 
bited by  the  echinococcus,  but  which  are  in  some  instances  sterile.  The 
above  name  has  been  given  to  this  formation  in  order  to  designate  that 
supposed  independent  vitality  which  the  absence  of  organs  still  renders 
problematical.  The  Acephalo-cyst,  which  Blainville  reckons  amongst 
the  "monadaires,"  and  Kuhn  compares  to  Agardh's  protococcus,  with 
its  multiplication  by  buds,  is  in  our  own  opinion  not  to  be  held  separate 
from  the  echinococcus,  although  the  precise  relation  between  the  ani- 
mal and  the  vesicle  is  by  no  means  clear. 

The  relation  of  the  primary  acephalo-cyst  [the  echinococcus-vesicle] 
to  the  outer  cyst,  is  analogous  to  that  of  a  new  growth  incapsuled  by 
exudation  from  the  surrounding  textures. 

1.  "W.  Griffith  has  examined  acephalo-cysts  and  their  contents.  The 
transparent  fluid,  of  1-008  sp.  grav.,  coagulated  readily  by  heat  or  nitric 
acid,  and  contained  an  inconsiderable  amount  of  fat.  A  thousand  parts 
yielded  fifteen  parts  of  solid  ingredients,  principally  common  salt.  They 
left  0-85  per  cent,  of  this  salt,  a  little  sulphate  of  soda,  a  trace  of  phos- 
phate of  lime,  and  some  albuminous  extractive  matter,  but  neither  choles- 
terine  nor  alkaline  phosphates.  The  envelopes  of  the  hydatids  left,  when 


270  VESICULAR    WORMS. 

dried,  a  brown  residuum,  which  dissolved  with  a  deep  brown  color  when 
boiled  with  hydrochloric  acid,  but  was  not  again  precipitated  on  the  ad- 
dition of  an  alkali.  When  moist,  they  dissolved  in  hydrochloric  and  in 
nitric  acid,  but  the  solutions  were  precipitated  neither  by  ferro-cyanide 
of  potassium,  nor  by  tincture  of  galls.  Nothing  was  dissolved  by  boiling 
them  in  water,  for  neither  by  tannic  nor  by  nitric  acid  was  either  any 
precipitate  formed,  or  the  fluid  gelatinized.  When  boiled  with  carbonate 
of  potash,  the  dried  membranes  were  dissolved  with  brown  coloration, 
but  without  any  accompanying  development  of  sulphuretted  hydrogen, 
nor  any  precipitation  on  the  addition  of  an  acid. 

Acephalo-cysts,  together  with  the  creatures  that  infest  them,  are  ex- 
tremely liable  to  destruction,  through  hypertrophy,  atrophy  and  conse- 
quent perforation  of  their  external  coat ;  but  most  particularly  through 
inflammation  of  the  latter  with  its  products. 

It  is  not  a  rare  thing  to  find,  within  a  sac,  individual  vesicles  imper- 
fectly filled,  or  collapsed,  with  walls  transparent,  tumefied,  gelatinized, 
or  even  degraded  to  a  smeary  mass.  The  contents  of  such  vesicles  are 
turbid.  They  consist  partly  of  fat-globules  with  a  fine  pulverulent  point- 
molecule  in  great  abundance,  and  the  ddbris  of  broken  up  echinococci. 
Occasionally  this  conversion  affects  most,  if  not  all  of  the  vesicles. 
They  burst  or  rather  open  out,  owing  to  the  increasing  tendency  to  dis- 
solution, until  at  length  the  entire  contents  of  the  parent  cyst  are  ren- 
dered turbid. 

The  inflammation  of  the  outer  sac,  a  frequent  occurrence,  is  impor- 
tant. It  bears  the  character  of  inflammation  of  a  sero-fibrous  mem- 
brane, and  throws  its  products,  for  the  major  part,  upon  the  inner  surface 
and  into  the  cavity  of  the  cyst. 

It  is  in  many  instances  to  be  regarded  as  a  fortunate  event,  leading  as 
it  does  to  the  disruption  and  extinction  of  the  acephalo-cyst,  with  its  in- 
habitant animalcules,  and  in  due  time  to  the  shrivelling  and  decay  of  the 
entire  sac.  The  contact  of  the  acephalo-cysts  with  exudate,  and  the  re- 
ception of  the  latter  through  endosmosis  into  the  walls  and  cavity  of  the 
acephalo-cysts  appear  to  be  amongst  the  most  ordinary  causes  of  their 
dissolution.  After  the  effusion,  gradual  resorption  of  a  portion  of  the 
contents — that  is,  of  the  original  serous  fluid,  and  of  the  exudate — fol- 
lows, whilst  another  portion  thickens  to  a  grayish,  unctuous  chalk-pap, 
and  eventually  cretifies  altogether.  The  sac  shrivelling  commensurately 
with  the  diminution  of  its  contents,  becomes  obliterated  in  such  wise  as 
ultimately  to  inclose  a  mass  consisting  of  variously  superimposed  residua 
of  acephalo-cysts  (echinococcus-vesicles)  and  of  the  said  chalk-pap  or  con- 
crement. 

It  is  not  unfrequent  for  an  intense  inflammation  to  terminate  in  ulce- 
ration  of  the  sac,  so  that  an  abscess,  inclosed  within  the  implicated  paren- 
chyma, takes  its  place.  This,  together  with  consecutive  suppuration  in 
neighboring  textures,  may  lead  to  the  opening  of  the  sac  into  another 
adjoining  one ;  or  to  its  opening  externally :  or  into  one  or  other  of  the 
great  serous  sacs ;  into  the  intestinal  canal ;  into  the  urinary  cavities  or 
passages ;  the  gall-ducts,  &c.  The  direction  in  which  such  an  abscess 
empties  itself  decides  the  question  as  to  the  favorable  or  the  unfavorable 
issue  of  the  case. 


BLOOD    DISEASES.  271 

The  echinococcus  and  acephalo-cyst  are  particularly  frequent  in  the 
liver,  less  and  less  so  in  the  subperitoneal,  areolar  tissue,  and  in  the  peri- 
toneum, in  the  omentum,  in  the  striated  muscles,  including  the  heart,  in 
the  brain,  in  the  spleen  [mostly  in  concurrence  with  others  in  the  liver], 
in  the  kidneys  ;  very  rare  in  the  lungs  and  bones. 

Not  unfrequently  they  occur  in  several  organs  simultaneously.  Thus 
they  will  infest  in  vast  numbers  both  the  peritoneum  and  the  abdominal 
viscera.  In  magnitude  the  sacs  may  attain,  or  even  exceed  the  diame- 
ter of  a  foot. 

The  echinococcus-cysts  may  become  perilous  through  their  volume ; 
and,  when  present  in  great  numbers,  prove  fatal  through  exhaustion  and 
general  wasting,  as  also  through  the  aforesaid  inflammatory  and  suppu- 
rative  processes. 

SPURIOUS   PARASITES. 

As  such  are  to  be  reckoned  all  those  foreign  bodies  reputedly  or  really, 
accidentally  or  designedly,  conveyed  upon  or  into  the  human  body ;  but 
which  are  proved  either  not  to  infest  it  in  reality,  or  to  be  of  a  nature 
even  manifestly  to  preclude  a  parasite  existence. 

We  have  to  bring  into  this  account  not  alone  animal  creatures,  and 
various  parts  of  animals  and  of  plants ;  but  also  misshapen,  diseased  tex- 
tural  parts  of  the  organism,  or  products  of  disease.  Such  are : 

1.  Animals  and  parts  of  animals  dead  or  alive,  really  voided  by  stool 
or  rejected  by  vomiting,  such  as  the  larvae  of  flies  received  into  the 
stomach  with  food  in  a  state  of  decomposition,  or  accidentally  or  design- 
edly added  to  the  matter  so  evacuated. 

2.  A  great  variety  of  other  bodies  of  the  descriptions  adverted  to. 
Amongst  the  spurious  parasites  of  the  present  day  we  may 'cite — 
(a.)    The  trichomonas  vaginalis  of  Donne*, — probably  a  misshapen 

ciliary  cell. 

(b.)  Diceras  rude  (Rudolphi),  repeatedly  recognized  as  the  undigested 
seeds  of  mulberries. 


BLOOD  DISEASES— DYSCRASES. 

Humoral  pathology  is  simply  a  requirement  of  common  practical  sense; 
and  it  has  always  held  a  place  in  medical  science,  although  the  limits  of 
its  domain  have,  no  doubt,  been  variously  circumscribed  or  interpreted 
at  different  times.  Of  late  years  it  has  met  with  a  new  basis  and  sup- 
port in  morbid  anatomy,  which,  in  the  inadequacy  of  its  discoveries  in 
the  solids  to  account  for  disease  and  death,  has  been  compelled  to  seek 
for  an  extension  of  its  boundary  through  a  direct  examination  of  the 
blood  itself. 

Not  alone  has  pathological  anatomy  demonstrated  the  existence  of 
blood  diseases  in  unlocked  for  detail ;  it  has  at  the  same  time  solved  a 
problem  of  the  weightiest  import.  It  has,  we  think,  decided  in  favor  of 


272  BLOOD    DISEASES. 

a  humoral  pathology,  by  demonstrating  a  primitive  anomaly  of  blaste- 
mata  ;  by  demonstrating  the  endogenous  impairment  of  the  blood  within 
the  vascular  system,  in  the  inflammatory  process,  as  the  basis  of  the  varia- 
tions in  exudates  [blastemata]  ;  lastly,  by  demonstrating  the  dependence 
of  local  morbid  action  upon  pre-existent  impairment  of  the  general  circula- 
tion. Our  attention  will  be  here  directed  to  diseases  of  the  blood  in  its 
totality,  and  to  local  dyscrasial  processes,  with  inflammation  at  their  head, 
only  in  so  far  as  these  offer  the  basis  and  starting-point  for  consecutive 
disease  of  the  entire  blood-mass.  It  is  remarkable,  however,  and  no  less 
important  for  practice  than  for  science,  that  the  essential  forms  of  these 
local  dyscrasial  processes, — perhaps  of  all  local  dyscrasial  disease, — 
occur,  likewise,  as  primitive  affections  of  the  entire  blood-mass.  This 
is  proved  by  the  varied  character  of  the  products  of  the  inflammatory 
dyscrasial  process,  and  a  comparison  in  detail  of  these  products  with 
anomalies  of  the  general  blood-crasis.  Thus,  primitive  pyaemia,  fibrin- 
crasis,  sepsis  of  the  blood,  severally  occur  independently  of  all  local 
beginning,  and  of  all  infection. 

There  are,  indeed,  two  ways  of  investigating  and  recognizing  blood- 
diseases  :  first,  the  anatomical  examination  of  the  blood  in  the  dead  sub- 
ject, or  of  blood  obtained  during  life  through  spontaneous  or  artificial 
hemorrhage ;  and  secondly,  chemical  analysis.  Both  kinds  of  investi- 
gation should  be  supported,  and  the  results  controlled,  by  a  concurrent 
examination  of  the  secretions  and  excretions,  of  the  general  condition  of 
the  solids,  and  of  new-formations,  especially  of  such  exudates  as  are  the 
offspring  of  inflammation. 

In  fine,  both  kinds  of  research  should  go  hand  in  hand.  For,  although 
a  deeper  insight  into  the  changes  suffered  by  the  blood  may  be  reserved 
for  chemistry,  it  must  needs  be  based  upon  sound  anatomico-humoral 
premises.  Up  to  the  present  day  chemistry  has  not  taken  this  duly  into 
consideration,  so  that  as  yet  this  science  cannot  be  said  to  have  far  ex- 
celled the  achievements  of  a  circumspect  anatomical  survey,  notwithstand- 
ing the  limited  resources  at  the  disposal  of  the  latter. 

Upon  the  chemical  pathologist  we  would  strongly  urge  an  unremitting 
prosecution  of  his  researches.  We  would  recommend  him  to  direct  his 
labors  more  particularly  towards  ascertaining  the  precise  character  of 
the  impairment  suffered  by  the  proximate  ingredients  of  the  blood,  and 
of  the  anomalies  impressed  upon  its  elementary  composition.  The  inte- 
rests of  hsemato-pathology  would  after  all,  perhaps,  be  best  served  by  the 
examination,  in  the  above  sense,  of  blood  taken  from  the  dead  subject, 
the  diagnosis  of  the  case  having  previously  received  the  light  of  a  general 
post-mortem  examination. 

Our  own  task  in  these  pages  will  be  limited  to  establishing  a  purely 
anatomical  pathology  of  the  blood ;  we  shall  therefore  restrict  ourselves, 
as  nearly  as  possible,  to  anatomical  facts,  although  without  neglecting  to 
avail  ourselves  of  the  collateral  support  of  such  chemical  data  as  may  be 
relied  upon  at  the  present  hour. 

It  is  the  business  of  pathological  anatomy  to  determine  both  the  phy- 
sical properties  of  the  blood  in  its  totality,  and  also  the  relative  quantity, 
and  more  especially  the  quality,  of  its  more  immediate  components. 


BLOOD     DISEASES.  273 

The  two  main  components  which  come  peculiarly  within  its  province  are, 
first,  those  essential  form-elements,  the  blood-globules  ;  and  secondly,  the 
spontaneously  separating,  coagulating,  solidifying  fibrin, — that  compo- 
nent which,  owing  to  its  varying  tendency  to  become  organized,  is,  in  an 
anatomical  sense,  the  most  important  of  all.  We  will  here  summarily 
refer  to  ivhat  has  been  said  in  the  introduction  to  the  doctrine  of  blaste- 
mata  and  to  the  section  on  exudates,  and  then  proceed  to  treat  of  blood 
diseases  in  what  would  appear  to  be  their  most  natural  order.  The  sub- 
ject is,  however,  so  intimately  allied  to  that  treated  of  in  the  chapters 
referred  to,  that  a  certain  amount  of  repetition  will,  perhaps,  be  unavoid- 
able in  the  following  pages. 

Affections  of  the  blood  are,  like  those  of  the  solids,  either  primitive  or 
consecutive.  And  again,  the  former,  equally  with  the  latter,  suggest  an 
inquiry  as  to  whether  they  result  from  an  immediate  influence  of  the 
morbific  agent  upon  the  blood,  or  are  determined  by  the  nervous  system, 
as  the  actual  percipient,  alienated  both  in  matter  and  in  function.  This 
question  can,  however,  hardly  affect  us  in  this  place,  since  the  latter  view 
mainly  rests  on  speculative  grounds,  and  upon  the  fact  that  obvious  injury 
to,  or  sensible  anatomical  disturbance  of,  the  nervous  system  sooner  or 
later  results  in  disease  of  the  blood. 

The  latter  are  determined  in  very  different  ways  by  anomalies  in  the 
solids.  Thus,  the  hindered  eliminating  activity  of  an  organ  occasions 
retention  of  effete  matter  in  the  blood  ;  an  abnormal  plastic  process  influ- 
ences the  blood  crasis,  directly  or  indirectly,  through  the  anomaly  in  the 
interchange  of  matter.  Take  for  example,  the  infection  of  the  blood 
within  the  range  of  an  inflammation. 

To  diseases  of  the  solids,  as  local  morbid  processes  in  the  broadest 
sense,  affections  of  the  blood  stand  in  a  twofold  relation  : 

1.  The  anomalous  crasis  is  a  pre-exist ent  one — the  primitive  affection  ; 
the  local  disease  a  localization  thereof — the  secondary  affection.     The 
point  of  localization,  apart  from  the  effect  of  concurrent  external  influ- 
ences, is  determined  by  a  specific  relation  of  the  crasis  to  certain  organs 
presided  over  by  the  nerves.     The  forms  it  assumes  are  chiefly  those  of 
hypergemia    and  stasis — inflammation,  absolute   stasis, — exudation,  or, 
without  the  latter,  a  product-formation  completed  within  the  bloodves- 
sels ;  for  instance,  spontaneous  coagulation  of  diseased  fibrin,  pus-forma- 
tion within  a  greater  bloodvessel  or  within  the  capillaries  of  an  organ. 

The  relation  of  the  various  erases  to  the  organs  and  textures,  nay,  even 
to  particular  sections  of  organs,  is  manifold.  Thus,  the  croupous  fibrin- 
erases  evince  a  very  marked  preference  for  the  mucous  membrane  of  the 
air-passages,  and  for  the  lungs  themselves ;  the  typhus-crasis,  for  the 
mucous  membrane  of  the  ileum ;  the  exanthematous  erases,  for  the  com- 
mon integument  and  for  mucous  membranes. 

2.  The  anomaly  of  the  general  crasis  is  consecutive ;  that  is,  the  con- 
sequence of  a  local  disease,  and  especially  of  local  dyscrasial  processes, 
whereof  the  products  are  taken  up  into  and  affect  the  general  blood-mass. 
This  happens — 

(a.)  Through  resorption  of  the  effused  products  by  means  of  the  lym- 
phatics, or  immediately  into  the  veins. 
VOL.  i.  18 


274  FIBRIN-CRASES. 

(&.)  Through  reception  into  patent  bloodvessels.  This  process  includes 
the  reception  of  products  thrown  out  into  the  cavity  of  larger  bloodves- 
sels,— pus,  for  example. 

(<?.)  Most  of  all,  through  the  off-flowing,  and  the  return  into  the  veins, 
of  plasma  degraded  in  the  local  process,  in  a  manner  corresponding  with 
the  quality  of  the  exudate.  [See  "  Relation  of  the  Inflammatory  Process 
to  the  Oasis."] 

It  is,  however,  to  be  understood  that,  neither  does  a  dyscrasis  neces- 
sarily always  become  localized,  nor  a  local  dyscrasial  process  invariably 
give  rise  to  a  consecutive  dyscrasis  of  the  entire  circulation.  In  the  for- 
mer case,  a  certain  degree  of  intensity  of  the  dyscrasis  is  no  doubt  requi- 
site ;  in  the  latter  case,  the  reception  of  a  sufficient  quantity  of  plasma, 
degraded  in  the  manner  aforesaid  by  the  local  process,  or  else  of  a  hete- 
rogeneously  diseased, — for  example,  of  an  ichorous  or  septically  consti- 
tuted— plasma  is  indispensable. 

Blood  diseases  are,  moreover,  either  protopathic,  whereby  we  mean 
developed  out  of  the  normal  crasis,  or  deuteropathic,  that  is  created  out 
of  another  anomalous  crasis.  [Meta-schematism.]  Deuteropathic  erases 
occur  in  the  simplest  manner,  as  impoverishment  of  the  blood  in  one  or 
more  ingredients,  drained  away  by  excessive  deposition  into  textures  or 
upon  membranous  expansions. 

Blood  diseases  are  both  acute  and  chronic,  and  they  are  marked  ac- 
cordingly by  the  rapidity  or  by  the  slowness  of  their  career.  This  is 
contingent  upon  the  character  of  the  *dyscrasis,  upon  its  grade,  and 
upon  the  significance  of  the  organ  in  wrhich  it  becomes  localized. 

They  issue : 

(a.)  In  transition  to  the  normal  blood-crasis.  This  occurs  under 
various  conditions,  for  the  most  part  obscure ;  for  example,  under  the  re- 
turn of  the  free  function  of  an  organ,  under  exhausting  localization  of 
the  dyscrasis  in  one  of  the  aforesaid  processes,  or  in  some  secretion.  In 
this  way  tuberculosis  and  cancer  may  lose  their  general  import  and  be- 
come local  affections,  which  either  go  on  vegetating  under  the  normal 
condition  of  the  blood,  or  enter  into  a  retrograde  metamorphosis. 

(b.)  In  transition  to  another  anomalous  crasis  [meta-schematism]. 
Such  transitions  are  multiform,  some  of  them  appearing  to  be  necessary 
conversions  when  the  original  crasis  is  at  its  acme,  others  to  represent 
the  final  wearing  out  of  some  component  of  the  blood.  With  respect  to 
others,  however,  we  are  still  in  every  way  completely  in  the  dark. 

(<?.)  In  death,  not  only  through  overwhelming  localization  in  vital 
organs,  often  coupled  with  palsy  of  their  function ;  not  only  through  ex- 
haustion of  organic  matter  and  of  the  powers  of  life,  owing  to  redundant 
local  production ;  but  also,  in  many  instances,  through  unfitness  of  the 
dyscrasial  blood  for  the  upholding  of  processes  essential  to  life,  for  the 
maintenance  of  nutrition  generally,  but  especially  of  respiration  and  of 
the  energies  of  the  entire  nervous  system,  both  central  and  peripheral. 

1.    FIBRIN-CRASES. 

The  fibrin-crasis  occurs  in  several  most  important  forms  and  varieties, 
which  the  term  hyperinosis — as  designating  a  frequent  but  by  no  means 


FIBRIN-CEASES.  275 

necessary  and  invariable  excess  in  the  quantity  of  fibrin — does  not  suffi- 
ciently characterize.  It  overlooks  the  far  more  important,  and,  for  the 
most  part,  very  marked  feature  of  quality.  However  certain  may  be  the 
excess  of  fibrin,  its  qualitative  deviation  becomes  more  and  more  distinctly 
pronounced  in  proportion  as  in  the  series  of  fibrin-erases  the  forms  recede 
from  the  characters  of  true  fibrin.  This,  with  the  exception  of  a  few 
hints  thrown  out  by  Andral,  has  been  hitherto  ignored.  In  this  qualita- 
tive anomaly,  however,  the  varieties  of  the  fibrin-erases  are  founded. 
Each  may  be,  and  very  often  is,  a  hyperinosis,  at  the  same  time.  Still 
the  qualitative  anomaly  is  the  essential  point ;  and  it  may,  in  a  hypinotic 
crasis — that  is,  in  poverty  of  fibrin — cling  to  a  minimum  of  fibrin,  and 
with  it  manifest  at  once  that  peculiar  tendency  of  fibrin-erases  to  locali- 
zation, and  a  marked  peculiarity  in  the  product. 

These  different  fibrin-erases  are,  as  in  the  sequel  their  special  delinea- 
tion will  show,  manifested  by  certain  anomalies  of  appearance  and  struc- 
ture. They  are  distinguished  in  common  by  the  proneness  of  their  fibrin 
to  coagulate,  and  by  its  deposition,  more  or  less  pure,  within  the  vascular 
system,  from  the  heart  to  the  capillaries  downwards.  They  are,  more- 
over, marked  by  their  localization  in  inflammations  which  are  wont  to 
affect  very  vascular  organs,  such  as  the  lungs,  mucous  and  serous  mem- 
branes, and  ar-eolar  tissue. 

The  fibrin-erases,  including  pyaemia,  tend  more  particularly  to  prove 
that  all  those  changes  which  the  plasma  undergoes  in  local  dyscrasial  in- 
flammation, and  its  products  or  exudates,  take  place  within  the  general 
circulation  and  by  virtue  of  its  own  intrinsic  relations,  not  through  any 
local  reciprocation  between  the  blood  and  the  textures -inflamed. 

The  fibrin-erases  constitute,  generally,  the  so-called  phlogistic  blood- 
admixture,  against  which,  conformably  with  the  view  of  a  quantitative 
exaltation  of  the  vital  process,  the  lancet  has  ever  been  opposed.  Yet 
amongst  the  processes  in  question,  far-sighted  pathologists  have  always 
discriminated  some  in  which  much  bleeding  appeared  not  only  needless 
but  even  mischievous  ;  we  refer  more  particularly  to  the  croupous  pro- 
cesses. That  in  these,  a  qualitative  deviation  in  the  constitution  of  the 
fibrin  plays  the  part  chiefly  deserving  of  attention,  is  proved  not  only  by 
the  more  obvious  anomalies  of  aspect  and  of  structure  before  alluded  to, 
but  also  by — 

1.  The  proneness  of  these  erases  to  become  localized,  even  where  the 
amount  of  anomalously  constituted  fibrin  in  the  blood  is  very  inconsi- 
derable ;  as,  for  instance,  in  the  secondary  croupous  erases  emerging  out 
of  the  typhus-crasis  ;  in  the  tuberculous  crasis,  in  which  the  last  particle 
of  fibrin  is  expended  in  the  deposition  (localization)  of  tubercle. 

2.  The  reaction  of  many  congenerous  exudates  upon  their  parent 
textures, — this  reaction  consisting  in  softening  and  corrosion. 

3.  The  wasting  attendant  upon  hyperinosis,  or  the  predominance  of 
fibrin,  that  element  of  the  blood  commonly  held  in  an  especial  manner  to 
preside  over  general  nutrition.    Here  the  alienation  of  functional  activity 
can  only  be  interpreted  as  qualitative. 

We  have  already  adverted  to  the  localization  of  the  fibrin-erases.  In 
relation  to  this,  it  is  a  question  equally  interesting  and  opportune, 


276  FIBRIN-CRASES. 

whether  the  erases  regarded  as  hyperinoses,  in  inflammations,  be  deter- 
mined  ly  the  latter -,  or  constitute  the  primary  and  fundamental  disease  ? 
The  view  received  in  France,  tends  to  demonstrate  the  dependence  of 
the  crasis  upon  the  local  inflammation  ;  in  other  words,  the  symptomatic 
character  of  the  crasis.  With  the  setting  in  of  the  inflammation  and  its 
increase,  the  amount  of  the  fibrin  is  supposed  to  become  augmented. 

We  are  fully  convinced  that  an  inflammation  obviously  called  forth  by 
external  causes  may,  by  the  abduction  of  endogenous,  and  the  resorption 
of  exuded  products,  give  rise  to  a  corresponding  crasis,  which  will  be- 
come augmented  in  proportion  as  the  inflammation  increases  in  intensity 
and  extent.  On  the  other  hand,  we  believe  that  spontaneous  stases  are 
localizations  of  a  crasis,  and  stand  to  it  in  a  dependent — a  conditional — 
relation.  This  opinion  is  based  upon  the  following  facts : 

1.  Every  crasis  [by  no  means  the  fibrinous  erases  alone,  to  which,  as 
the  so-called  phlogistic,  we  might  be  disposed  to  concede  this  preroga- 
tive] is  capable  of  localizing  itself  in  the  shape  of  inflammation  ;  take  for 
example,  the  typhous  and  the  exanthematous  erases.      The  objection  that 
inflammations,  and  especially  pneumonia,  arise  during  the  progress  of 
typhus,  is  met  by  the  fact  that  those  inflammations  with  the  character 
of  a  fibrin-crasis   are   based  upon  a   fibrino-croupous  crasis — in  other 
words,  that  they  are  the  localization  of  a  fibrino-croupous   crasis  into 
which  the  typhus  has  become  converted.     Genuine  typhous  pneumonia 
(pneumo-typhus)  does  not  develope  a  fibrin-crasis,  any  more  than  does 
typhous  inflammation  of   the  intestinal*  follicles  or  of  the  mesenteric 
glands. 

An  objection  of  considerable  weight  against  the  opinion  promulgated 
by  Andral,  is  furnished  by  pneumonia,  the  very  process  commonly  con- 
current with  the  most  marked  hyperinosis.  We  believe  that  ordinary 
pneumonia  [with  fibrinous  product]  is,  for  the  most  part,  the  localization 
of  a  pre-existent,  that  is,  precursorily  developed  crasis,  a  crasis  charac- 
terized by  an  incontestable  relation  to  the  lungs,  and  to  the  mucous 
membrane  of  the  air-passages.  Such  a  view  does  away  with  the  paradox 
that  inflammation  of  the  lungs,  a  disease  which,  in  its  intense  form,  at- 
tacks and  disables  large  sections  of  the  lung,  should  uphold  so  enormous 
a  development  of  fibrin,  whilst  other  lung  diseases  lead  to  erases  of  the 
very  opposite  kind — in  a  word,  to  venosity  [Hypinosis,  Albuminosis, 
Cyanosis]. 

2.  Lastly,  the  argument  derives  force  from  the  general  disturbance 
which  always  precedes   a  localization,   seeming   to  bear  witness  to  an 
alteration  in  the  crasis.     And  to  this  may  be  added,  the  nature  of  the 
causal  influences,  which  appear  to  be  rather  general  than  local.     We 
may  instance  epidemics,  climate,  weather,  &c. 

Fibrin-erases  become,  for  the  most  part,  primitively  developed  under 
the  conditions  of  a  free  respiratory  function.  Of  this  fact,  striking  ex- 
amples offer  in  the  tuberculoses,  and  the  setting  in  of  croupous  and  of 
tuberculous  processes  after  childbirth,  that  is  to  say,  after  the  release  of 
the  thoracic  spaces  and  of  the  lungs,  resulting  from  deliverance  of  the 
womb. 

Certain  fibrin-erases  are  primary,  and  distinguished  by  their  localiza- 
tion upon  the  mucous  membrane  of  the  air-passages  [laryngeal, 


SIMPLE    FIBRIN-CRASTS.  277 

tracheal,  bronchial,  pulmonary  croup],  upon  serous  and  sjnovial  mem- 
branes, and  in  large  accumulations  of  areolar  tissue.  Others  are  secon- 
dary, that  is,  the  consequence  or  the  conversion  of  other  erases,  for  ex- 
ample, of  the  typhus-,  of  the  exanthema-,  of  the  cholera-crasis.  In 
these,  a  qualitative  anomaly  of  the  fibrin  predominates,  as  shown  by 
this,  that,  even  where  but  an  inconsiderable  amount  of  fibrin  becomes 
developed,  localization  takes  place,  and  this  of  an  unwonted  kind,  as,  for 
instance,  upon  the  mucous  membrane  of  the  intestinal  tract,  of  the 
urinary  passages,  of  the  gall-ducts,  &c.  Others,  again,  are  primitive, 
spontaneous,  or  even  consecutive  affections  of  the  blood  determined  by 
infection  with  analogous  substances.  They  are  often  epidemical. 

Above  all  other  erases,  the  fibrin-erases,  like  the  fibrin-exudates,  are 
never  thoroughly  pure.  Every  portion  of  morbid  fibrin  has,  associated 
with  it,  another  portion  of  less  diseased,  or  even  of  normal  fibrin. 

The  products  of  the  localized  fibrin-erases  [endogenous  coagulations, 
and  especially  exudates  engendered  by  inflammatory  stasis]  are  partly 
organizable  [designed  for  regeneration,  or  expended  in  hypertrophy], 
partly  unorganizable,  liquefying,  corrosive,  purulent,  or  ichorous.  These 
exudates  correspond  so  completely  with  the  nature  of  the  coexistent 
fibrin-coagula  within  the  vascular  system,  that  the  character  of  the  one 
may  with  safety  be  inferred  from  an  acquaintance  with  the  other. 

It  is  interesting  that  coagulations  in  the  left  heart,  that  is  out  of  arte- 
rial blood,  are  not  alone  more  decidedly  compact,  but  also  more  frequent 
than  those  out  of  venous  blood.  As  evidence  of  this  we  may  cite  the 
incomparably  more  frequent  globular  vegetations  in  the  arterial  cham- 
bers of  the  heart. 

As  yet,  chemical  analysis  has  contented  itself  with  demonstrating  the 
quantitative  excess  of  fibrin  in  the  blood.  According  to  our  own  re- 
searches, however,  investigations  are  urgently  requisite  which  have  for 
their  principal  aim  to  determine  the  qualitative  impairment  of  the  fibrin. 
An  augmentation  of  the  fibrin  is  always  coupled  with  a  diminution  in  the 
amount  of  blood-globules,  and,  as  chemists  maintain,  at  the  same  time 
with  an  increase  in  the  proportion  of  fat  present  in  the  blood.  This 
certainly,  however,  does  not  apply  to  every  fibrin-crasis. 

Fibrin-erases  attended  with  great  exudation,  frequently  bequeath,  as 
consequent  upon  the  exhaustion  of  fibrin,  a  condition  of  hypinosis  [defi- 
brination],  and  of  hydraemia.  They  eventually  prove  fatal  from  this 
source,  if  the  patient  have  escaped  the  deadly  influence  of  paralysis  of 
the  organ  of  localization,  or  of  spontaneous  coagulation  in  important 
sections  of  the  vascular  system  ;  for  instance,  in  the  ramifications  of  the 
pulmonary  artery.  The  highest  grades  of  dyscrasial  fibrin-constitution, 
finally  degenerate  into  sepsis  of  the  fibrin,  and,  indirectly,  of  the  entire 
blood-mass. 

The  crasis  may  also  terminate  in  restoration  of  the  normal  crasis, 
through  conversion  of  the  morbid  excess  of  fibrin  into  nitrogenous  sub- 
stances, eliminated  with  the  urine  and  perspiration.  The  fibrin  thus  be- 
comes largely  converted  into  excrementitious  matter. 


278  CROUPOUS    CRASIS. 


(a.)   SIMPLE   [ORGANIZABLE   FIBRIN-YIELDING]   FIBRIN-CRASIS. 

It  is  the  attendant  upon  inflammations  with  an  organizable  exudate, — 
that  is,  an  exudate  susceptible  of  textural  conversion.  It  comprises  the 
inflammations  of  wounds  healing  by  the  first  intention ;  many  inflamma- 
tions of  glandular  organs,  and  of  serous  and  synovial  membranes  which 
terminate,  not  in  purulent  liquefaction  of  their  products,  but  in  gradual 
resorption  or  in  textural  conversion  of  the  latter, — or  in  the  case  of 
pneumonia,  in  obliteration  of  the  pulmonary  texture. 

The  product  of  these  processes — that  is,  the  exudate-fibrin  determined 
by  these  processes — answers  to  the  character  of  fibrin  2.  [See 
"Fibrin."] 

The  crasis  consists  in  this :  namely,  that  the  fibrin,  besides  increase 
in  quantity,  usually  manifests,  within  the  bloodvessels,  the  character  of 
the  exudate-fibrin  just  adverted  to  ;  in  other  words,  those  qualities  which 
fibrin  acquires  in  certain  processes  of  inflammation.  The  tendency  of 
fibrin  to  coagulate  is  sometimes  aggravated  into  spontaneous  coagulation 
within  the  vascular  system. 

The  coagula  are  white,  or  yellowish- white,  compact,  frequently  holding 
enclosed  a  notable  quantity  of  serum.  Under  a  closer  inspection  they 
appear  as  a  glebous,  fibro-glebous  blastema,  here  and  there  delicately 
fibrillated  in  wavy  curls.  Through  this  are  interspersed  numerous  black- 
contoured,  spherical  or  fibre-drawn  nuclei,  along  with  scattered,  dull- 
granular  nuclei,  and  nucleated  cells.  All  the  nucleus-formations  are 
rendered  more  sharply  defined  by  the  influence  of  acetic  acid,  the  blas- 
tema itself  becoming  turgescent  and  transparent.  [See  "Fibrin  2."] 

To  this  category  belong  not  a  few  of  the  so-called  vegetations  or 
fibrin-coagula  within  the  heart's  cavities,  not  a  fewT  coagula  in  bloodves- 
sels of  every  calibre  down  to  the  capillaries,  perhaps  also  the  intra- 
arterial  stratiform  coagula,  and  those  endogenous  depositions  which  are 
the  primitive  source  of  phlebolites. 

Unless  these  coagula — produced  during  life — be,  in  a  state  of  minute 
subdivision,  taken  up  again  into  the  blood,  they  enter  into  a  textural 
conversion. 

The  crasis  is  either  a  spontaneous,  primitive,  or  else  a  consecutive  one 
engendered  by  infection  of  the  blood  with  a  product  of  a  corresponding 
kind. 

The  dead  subject  is  marked  by  great  cadaveric  rigidity,  by  firm,  deep- 
red  muscles,  by  tense,  dry  areolar  tissue,  and  by  retarded  lividity  and 
decomposition. 

(5.)   THE   CROUPOUS   CRASIS   [PIORRY'S   H^MITIS.] 

The  croupous  crasis  occurs  under  several  forms,  which  at  the  same 
time  represent  various  gradations  of  disease  of  the  fibrin.  Amongst 
them  we  find,  on  the  one  side,  the  most  marked  hyperinoses ;  on  the 
other,  a  scanty  proportion  of  fibrin,  but  that  deeply  affected  in  quality. 
This  is  manifested  first  by  its  augmented  coagulability,  by  a  greatly  in- 
creased tendency  to  deposition  in  the  shape  of  intra-vascular  coagulation 


CROUPOUS     CRASIS.  279 

[in  the  capillaries,  as  capillary  phlebitis],  and,  lastly,  by  acute  processes 
of  exudation. 

Both  the  intra-vascular  coagula  and  the  exudates  are  distinguished  by 
their  indisposition  to  become  organized,  by  their  early  liquefaction,  and 
very  often  by  their  corroding,  solvent  effect  upon  the  textures.  Both 
are  opaque,  yellow,  or  of  a  greenish-yellow,  and  contain  fat.  The  adhe- 
sive property  gradually  diminishes. 

To  the  latter,  namely,  the  exudates,  must  be  reckoned  some,  exhausting 
by  their  volume  and  abundance,  others  inferior  in  quantity,  but  indi- 
cating, by  their  tendency  to  liquefy  and  by  their  reaction  upon  the  tex- 
tures, the  deep  impairment  of  the  fibrin. 

They  are  often  idiopathic,  but  more  frequently  consecutive  erases, 
emerging  out  of  others, — the  typhous,  the  exanthematous,  &c.  In  the 
former  case  they  are  marked  hyperinoses ;  in  the  latter  case  they  are 
determined  by  inflammation,  and  the  infection  of  the  blood  with  conge- 
nial products.  They  constitute  the  so-called  hsemites  of  Piorry. 

In  their  processes  of  exudation,  they  evince  a  preference  for  the 
mucous  membranes,  especially  of  the  respiratory  and  of  the  digestive 
tracts,  as  also  for  the  serous  and  synovial  membranes. 

CROUPOUS   CRASIS  a. 

It  is  characterized  by  the  following  relations  of  the  fibrin  in  its  coagu- 
lation and  exudation. 

The  coagula — engendered  in  the  death-agony — are,  in  the  heart,  either 
clod-like,  cord-like,  more  or  less  compact  masses  prolonged  into  the 
bloodvessels,  or  where  the  energy  of  the  heart's  systole  has  been  broken 
long  prior  to  death,  and  the  mortal  struggle  protracted,  membranaceous, 
lining  the  heart's  cavities  or  insinuating  themselves  in  the  shape  of  fangs 
amongst  the  trabeculae.  When  developed  during  life,  they  appear,  in 
the  heart,  as  the  liquefying  so-called  globular  vegetations;  in  wide- 
calibred  bloodvessels,  as  cylindrical  and  plugging,  or  as  membranaceous, 
coagula  loosely  attached  to  the  internal  membrane  of  the  bloodvessel ; 
in  capillary  ranges,  as  obstructions  of  the  texture  varying  in  circumfe- 
rence. They  are  either  pure  fibrin  or  contain  more  or  fewer  blood- 
globules,  incorporated  with  them  during  the  act  of  precipitation.  In  the 
former  case,  they  are  marked  by  their  opacity,  by  their  dull  white,  yel- 
lowish, or  yellowish-green  coloration.  In  the  latter  case,  they  are  like- 
wise opaque,  but,  according  to  the  amount  of  contained  blood-globules, 
more  or  less  reddened. 

A  closer  inspection  shows  the  coagula  to  consist  of  a  glebous-like, 
fibro-glebous  blastema,  or  of  a  faintly  striated,  membranous  basement, — 
like  the  inner,  the  fenestrate,  bloodvessel  membrane,  bestrewn  with  point- 
molecule,  with  numerous  granulated,  grayish  nuclei  or  nucleus-like 
formations,  and  with  similar  granulated  cells.  All  the  nucleus  forma- 
tions are  uninfluenced  by  acetic  acid,  except  that  a  slight  shrinking 
takes  place,  and  that  they  acquire  a  somewhat  sharper  outline.  Not 
unfrequently  the  entire  coagulum  seems  to  consist  of  these  nucleus-  and 
cell-formations,  along  with  a  proportion  of  point-molecule.  [See  "  Fi- 
brin 3."] 


280  CROUPOUS    CRASIS. 

The  metamorphosis  of  these  coagula  consists  for  the  most  part  in  a 
tolerably  rapid  liquefaction  of  the  blastema  to  a  puriform,  tenacious  fluid 
holding  the  aforesaid  form-elements  in  suspension. 

The  exudates,  reflecting  the  hyperinotic  condition  of  the  blood,  are 
generally  very  abundant,  even  to  the  exhaustion  of  the  fibrin.  They 
are  reddened  in  a  degree  conformable  with  the  amount  of  extravasated 
blood  which  they  have  incorporated, — as,  for  instance,  in  hepatization  of 
the  lung.  Or  they  are  of  a  grayish-yellow  with  a  slight  shade  of  green, 
and  opaque.  Their  metamorphosis  consists,  possibly  with  textural  trans- 
formation of  any  organizable  portion,  in  disintegration  and  liquefaction 
of  the  blastema  to  a  pus-like,  tenacious  fluid.  [See  "  Croupous  Exu- 
date  a."] 

CROUPOUS   CRASIS  /3. 

Its  characters  are  nearly  those  of  the  former,  as  regards  the  outer 
aspect  of  the  coagula  and  of  the  exudates,  only  more  strongly  developed. 
Thus,  the  opacity  of  the  coagula  and  of  the  exudate-fibrin  is  more  consi- 
derable ;  their  coloration,  where  they  do  not  include  blood-corpuscles, 
more  decidedly  of  a  greenish-yellow.  Their  metamorphosis  consists  in 
rapid,  puriform  liquefaction. 

More  narrowly  scrutinized,  the  coagula  are  found  to  consist  of  a  fine, 
dense  point-molecule,  of  nucleus-  and  cell-formations  in  different  degrees 
of  completeness  and  of  assimilation  to* the  pus-cell.  These  are  held 
together  through  the  instrumentality  of  an  amorphous  bond-mass.  En- 
gendered during  life,  they  break  up — the  blastema  liquefying — into  a 
tenacious  fluid,  in  which  the  elements  specified  are  held  in  suspension ; 
and  which,  in  proportion  as  the  cells  predominate,  more  and  more 
resembles  pus.  [See  "Fibrin  4."] 

The  exudates,  corresponding  in  character  with  the  usually  hyperinotic 
condition  of  the  blood,  are  generally  very  copious,  exhausting,  of  a 
yellowish  or  a  greenish-yellow  tint,  imperfectly  adherent  to  the  exuda- 
tion-surface, rapidly  liquescent  to  a  puriform  fluid,  and  of  a  form- 
composition  identical  with  that  of  the  coagula.  [See  Croupous  Exu- 
date  /5.] 

In  both  the  coagula  and  the  exudates,  the  basement  or  blastema  con- 
necting the  form-elements  has  lost  the  fibrillation  so  characteristic  of 
coagulating  normal  fibrin,  and  even  the  glebe-like  structure. 

Certain  conditions  are  common  to  both  varieties  of  the  croupous  crasis 
[a  and  /?] ;  to  the  latter,  however,  they  apply  in  a  higher  degree. 

Both  become  localized  in  the  shape  of  exudatory  processes  upon  the 
mucous  membranes,  especially  of  the  respiratory  tract ;  in  early  youth, 
in  the  larynx  and  trachea ;  at  a  later  period,  in  the  bronchia ;  and  from 
the  period  of  puberty  to  the  end  of  life,  in  the  lungs  [as  laryngo-tracheal, 
as  bronchial  croup,  and  as  croupous  pneumonia].  Upon  the  mucous 
membrane  of  the  womb,  as  also  upon  the  great  serous  sacs,  especially 
the  peritoneum,  with  or  without  congenerous  puerperal  metritis,  they 
become  located,  as  puerperal  processes ;  in  the  synovial  sacs,  as  acute 
rheumatism ;  again,  as  endocarditis  and  inflammation  of  bloodvessels ; 
lastly,  in  the  areolar  tissue,  the  pia  mater,  the  spleen. 


CROUPOUS    CRASIS.  281 

They  also  become  localized  as  the  metastatic  deposits  of  capillary 
phlebitis. 

The  high  grade  of  the  internal  dyscrasial  influence  is  no  doubt  the 
cause  "why  a  protracted  stasis  is  not  requisite  for  product-formation  ; 
why,  therefore,  the  exudation  takes  place  very  rapidly ;  and  why,  not- 
withstanding the  great  bulk  of  the  exudate  and  the  lax  and  vulnerable 
nature  of  the  textures,  it  is  not  hemorrhagic  ;  in  other  words,  why  it  is 
not  attended  with  any  extensive  laceration  of  the  bloodvessels.  There 
is  little  doubt  that  the  pneumonias  stated  by  Hodgkin  to  enter  at  once 
into  yellow  and  rapidly  liquefying  hepatization,  belong  to  this  class. 

By  long  contact,  the  deliquescent  coagula  and  exudates  frequently 
exert  a  solvent,  corrosive  power  upon  the  textures.  In  this  manner 
they  determine  fresh  inflammation,  ulcerous  loss  of  substance,  phthisis 
of  the  organs,  secondary  phlebitis,  pulmonary  abscess,  phthisis  of  the 
peritoneum,  of  the  pleura,  and,  along  with  these,  of  the  abdominal  and 
thoracic  parietes. 

Or  again,  they  become  re-absorbed,  or  else,  owing  to  the  changes 
attendant  upon  their  disintegration,  they  undergo,  together  with  partial 
absorption,  fatty  conversion,  usually  followed  by  inspissation  and  crete- 
faction. 

One  further- phenomenon  here  finds  its  elucidation,  namely,  the  milky 
Hood.  This  has  been  witnessed  in  pneumonia  and  peritonitis,  and  we 
have  ourselves  encountered  it  in  a  developed  form  in  pneumonia,  and  in 
very  intense  inflammation  of  the  spleen.  Such  blood  has  been  found  to 
contain  an  excessive  proportion  of  fat ;  it  is,  however,  questionable  whe- 
ther this  be  the  sole  cause  of  the  phenomenon.  We  believe  the  latter 
to  be  due  rather  to  the  disintegration  of  croupous  fibrin  within  the  cir- 
culation, in  other  words,  to  the  suspension  of  the  point-molecule  [the 
molecular  fibrin]  in  the  blood-serum.  It  is  very  possible,  indeed,  that  a 
fatty  condition  of  the  blood  may  contribute  to  produce  the  milky  ap- 
pearance ;  and  not  improbable  that  in  some  cases  of  a  different  kind,  for 
example,  in  the  blood  of  dram-drinkers,  it  may  be  the  sole  cause. 

The  rigor  mortis  manifests  itself  in  the  inverse  ratio  of  the  magnitude 
of  the  effusion,  and  the  same  inverse  relation  obtains  between  the  latter 
and  the  intra-vascular  fibrin-coagula.  The  blood  is  in  part  loosely 
clotted ;  for  the  most  part  fluid  ;  owing  to  simultaneous  loss  of  serum 
through  exudation,  tenacious  ;  and  of  a  dark  cherry-red  [defibrination]. 
It  forms,  in  every  variety  of  organs,  dirty-red  hypostases  ;  death-patches 
become  rapidly  and  extensively  developed ;  the  liver  is  dark-colored. 
The  muscles  are  lax,  the  parenchymata  collapsed,  flabby,  lacerable, 
moist,  and  where  there  is  no  hypostasis,  pallid. 

CROUPOUS  CRASIS  f.   APHTHOUS  CRASIS. 

In  the  croupous  erases  hitherto  described  hyperinosis  commonly  pre- 
vails ;  in  the  crasis  we  are  now  entering  upon,  the  amount  of  fibrin  in 
the  blood  is  for  the  most  part  scanty.  By  so  much  the  more  significant 
must  be  the  anomaly  in  the  quality  of  the  fibrin  and  in  the  general 
crasis,  and  we  shall  presently  see  this  to  be  really  the  case,  if  we  extend 
the  idea  of  this  crasis  in  a  natural  order  beyond  that  constitution  of  the 


282  TUBERCLE-CRASIS. 

blood  proper  to  ordinary  aphthae  as  affecting  the  mucous  membrane  of 
the  mouth. 

The  exudates  appertaining  to  the  croupous  erases  before  described 
occasion  destruction  of  the  textures  only  after  long-continued  contact 
with  them,  and  in  their  secondary  phase  of  disintegration.  In  the  aph- 
thous  exudates  this  effect  is  produced  at  once,  and  as  it  would  seem 
during  the  process  of  exudation  itself. 

The  exudates  are  yellow,  greenish-yellow,  dingy  gray,  opaque,  tough 
products,  which,  upon  superficial  expansions,  coagulate  in  a  pseudo-mem- 
branous form,  and,  together  with  the  textures,  rapidly  break  up.  They 
are  very  often  remarkable  for  the  exuberant  epiphyte-formations  [thread- 
funguses]  which  take  root  in  them.  The  disintegration  manifests  itself 
in  various  forms,  doubtless  connected  most  intimately  with  the  grade  and 
with  the  modification  of  the  crasis,  from  simple  corrosion  with  secondary 
reactive  inflammation  in  the  vicinity  [aphthae],  down  to  fusion  to  a  vari- 
ously discolored,  fetid,  ichorous  pulp,  or  to  a  tough  or  a  friable  slough, 
that  tears  like  soft  agaric. 

With  this  the  crasis  has  attained  the  phase  of  a  putrid  decomposition, 
a  sepsis,  a  necrosis  of  the  fibrin  and  of  the  general  circulating  fluid. 
The  blood  is  discolored  and  contains  partly  tough,  partly  pap-like,  dis- 
colored, ichorous,  coagulate  fragments — as  exemplified  in  diphtheritis, 
sloughing  tonsils,  puerperal  putrescence  of  the  womb,  septic  dysen- 
tery, &c.  The  seat  of  such  processes  is  above  all  in  the  mucous  mem- 
branes, especially  of  the  alimentary  tubb,  of  the  urinary  bladder,  of  the 
female  sexual  organs  and  their  follicles  ;  in  open  wounds  and  sores,  in 
areolar  tissue,  in  common  integument.  Amongst  them  may  be  reckoned 
thrush  [diphtheritis] ;  certain  exudation-processes  upon  the  mucous 
membrane  of  the  intestinal  canal,  especially  of  the  colon  [as  a  form  of 
dysentery],  and  of  the  uterus  after  delivery  ;  corrosive  fibrin-exudates 
upon  the  mucous  membrane  of  the  urinary  bladder  ;  upon  external  and 
internal  sores  ;  muco-membranous  ulcers,  especially  upon  the  base  of  the 
typhous  ulcers ;  white  gangrene  of  the  common  integuments  [hospital 
gangrene]. 

The  aphthous  crasis  is  often  idiopathic.  It  is,  however,  no  less  fre- 
quently consecutive  upon  other  anomalous  erases,  and  upon  the  typhous, 
the  typhoid,  the  exanthematous  in  particular.  The  blood,  reduced  in 
quantity,  presents  the  characters  proper  to  those  erases ;  the  few  coa- 
gula  themselves,  the  characters  of  excessively  croupous  fibrin. 

The  dead  body  is  collapsed,  devoid  of  rigor.  The  death-patches 
become  speedily  discolored  to  russet  and  green.  Muscles,  flabby,  pale. 
Parenchymata,  collapsed,  friable.  The  blood,  wasted,  dusky-red,  fluid, 
with  a  few  villous,  broken  coagula,  marked  by  opacity,  toughness,  dis- 
coloration, and  septic  disintegration. 


(c.)    THE  TUBERCLE-CRASIS. 

Although  there  are,  no  doubt,  tuberculoses  purely  local,  a  tuberculosis 
extending  through  several  organs,  or  even  through  one  entire  organ,  is 
invariably  the  offspring  of  a  tuberculous  dyscrasis. 


TUBERCLE-CRASIS.  283 

The  latter  is  for  the  most  part  developed  out  of  a  fibrin-crasis.  In 
the  dead  subject,  a  hyperinosis  of  the  blood  may  not  be  ostensible. 
Nay  !  owing  to  the  frequent  and  voluminous  processes  of  exudation  at- 
tendant upon  the  course  of  a  tuberculosis,  a  poverty  in  fibrin  is  perhaps 
more  likely  to  reveal  itself  after  death.  Excess  of  fibrin  has,  however, 
been  demonstrated,  in  such  cases,  by  the  chemical  examination  of  blood 
withdrawn  during  life,  and  it  may  also  be  inferred  from  the  extent  of 
the  tuberculous  deposition.  Still  the  hyperinosis  is  far  from  being  ade- 
quate to  account  for  the  disease.  It  is  the  qualitative  anomalies  of  the 
fibrin  that  must  determine  its  tuberculous  nature, — anomalies  of  quite  a 
peculiar  kind,  which,  as  we  shall  see,  may  modify  every  one  of  the 
fibrin-erases  referred  to  into  the  tuberculous. 

The  gray  tubercle  answers  to  the  character  of  the  simple  fibrin-crasis. 
[See  "  Gray  Tubercle."] 

The  opaque,  yellow,  lardo-caseous  tubercle,  marked  by  its  proneness 
to  undergo  softening,  answers  to  the  character  of  the  croupous-crasis. 
[See  "  Yellow  Tubercle."] 

We  have  remarked  of  the  products  of  the  fibrin-erases  that  they  are 
seldom  unalloyed.  The  same  observation  applies  to  the  products  of 
the  tuberculous  crasis.  The  products  of  the  one  always  occur  inter- 
mingled with  elements  of  the  other  ;  and  tuberculous  products  may  even 
include  more  or  less  of  organizable  elements  which  form  into  textures  in 
the  ordinary  way. 

Again,  the  transitions  of  the  individual  tubercle-crasis  from  one  to 
another  are  obviously  brought  about  step  by  step.  The  croupous  tuber- 
cle appears  but  rarely  as  the  primitive  tubercle.  It  is  generally  based 
upon  a  pre-existent  gray  tubercle,  and  the  croupous  tubercle  appears  as 
an  aggravation  of  the  simple  form. 

In  the  fibrin-erases  a  minimum  of  fibrin  suifices  for  the  groundwork  of 
a  qualitative  impairment,  and  this  in  its  amplest  sense  applies  to  tubercle. 
The  smallest  proportion  of  fibrin  present  in  the  blood  takes  on  the  taint 
and  becomes  expended,  up  to  the  point  of  complete  defibrination,  in  the 
deposition  of  tubercle. 

Still  these  said  erases  by  no  means  serve  to  throw  much  light  upon 
the  nature  of  tuberculosis.  They  must  needs  involve  a  peculiar — a  tu- 
berculous— modification,  the  existence  of  which  is  indeed  proved  by  the 
tuberculization  of  extra-vascular  fibrin  in  hemorrhage,  and  also  of  intra- 
vascular  fibrin-coagula.  In  this  modification  must  be  rooted: 

(a.)  The  surpassing  proneness  of  the  fibrin  to  deposition,  so  frequently 
brought  about  in  quite  an  insensible  manner ; 

(6.)  The  assumption  by  the  deposited  fibrin  of  the  particular  form  of 
tubercle.  The  granulation  of  tuberculous  products  of  inflammation  upon 
serous  membranes  might  indeed  be  ascribed  to  a  separation  of  the  tuber- 
culous portion,  due  to  its  great  coagulability.  Still  the  very  localization 
of  the  tubercle-crasis,  in  such  minute  and  sharply-defined  areae  that  little 
granule-shaped  exudates  are  the  result,  constitutes  a  peculiarity — a  re- 
markable peculiarity,  seeing  that  the  same  form  of  separation — the  same 
form  of  tuberculization — attaches  to  the  fibrin  of  hemorrhage  and  to  en- 
dogenous vascular  coagula. 


284  TUBERCLE-CRASIS. 

(<?.)  The  fact  that  blastemata  resulting  from  the  tuberculous  fibrin- 
erases  do  not  undergo  the  metamorphoses — proper  to  the  pure  fibrin- 
exudates — of  textural  formation  on  the  one  side,  and  of  rapid  purulent 
liquefaction  on  the  other ;  but  throw  off  their  exudate-water  in  the  act 
of  firm  coagulation,  and  tarry  for  a  while  in  this  crude  state  of  consolida- 
tion. This  respite  is  of  various  duration,  but  at  all  events  exceeds  both 
that  proper  to  textural  conversion,  and  that  common  to  disintegration, 
in  corresponding,  purely  fibrinous  exudates. 

As  the  most  marked  and  obvious  phenomena  connected  with  tubercle 
must  be  specified  its  high  grade  of  coagulability,  and  its  surpassing  prone- 
ness  to  deposition, — to  the  localization  of  its  crasis.  In  these  are  with- 
out doubt  centred  the  peculiarities  of  the  fibrin-erases  in  their  tuberculous 
modifications. 

If,  in  relation  to  these  peculiarities  of  tuberculous  fibrin,  we  take  into 
account : 

(a.)  The  consummate  coagulability  of  arterial  fibrin  generally ; 

(b.)  Its  supreme  sensitiveness  towards  heterogeneous  substances,  such 
as  inflammatory  products,  whose  reception,  for  example,  in  arteritis,  oc- 
casions locally  so  rapid  an  obstructing  coagulation  of  the  blood-column, 
as  to  obviate  any  infection  of  the  general  blood-mass  from  that  point. 
[See  "Arteritis,"  vol.  iv.] 

(c.)  The  ready  deposition  of  fibrin  out  of  arterial  blood,  as  stratiform 
coagula  upon  the  inner  arterial  surface,  a  disease,  in  its  consummate 
form,  peculiar  to  arteries. 

(d.)  The  very  common  localization  both  of  the  fibrin-erases,  whether 
spontaneous  or  determined  by  infection,  in  the  shape  of  exudate,  or  of 
endogenous  coagulation  within  the  capillaries  of  the  arterializing  organs 
[the  lungs],  and  again  the  still  more  marked  relation  of  the  tuberculous 
crasis  to  these  viscera. 

(e.)  On  the  one  side,  the  pre-eminent  development  of  the  pulmonary 
organ  as  predisposing  to  the  fibrin-erases  in  general,  and  to  their  tuber- 
culous modification  in  particular ; 

(/.)  On  the  other  side,  the  pre-eminent  immunity  afforded  by  exquisite 
venosity  and  cyanosis,  against  fibrin-erases,  more  especially  the  higher 
(croupous)  grades,  and  most  particularly  against  the  tuberculous  crasis, 
— taking,  we  say,  all  these  circumstances  duly  into  account,  we  are  forced 
on  to  the  momentous  conclusion  that  arteriality,  that  is,  the  arterial  de- 
velopment of  the  fibrin,  pre-eminently  constitutes  the  cardinal  character 
of  tuberculosis. 

The  qualitative  impairment  of  the  blood-fibrin  here  again,  as  in  the 
fibrin-crasis  of  a  higher  grade,  serves  to  explain  summarily  the  fact,  that 
in  individuals  with  blood  impoverished  in  fibrin, — or  even  generally  im- 
poverished,— tubercle  continues  to  become  deposited.  It  has  been  else- 
where affirmed,  and  it  is  worthy  of  repetition  here,  that  in  such  cases 
every  atom  of  tuberculo-dyscrasial  fibrin  becomes  expended  in  the  form- 
ation of  tubercle.  This  view  clears  up  the  seeming  inconsistency  of 
affirming  tubercle  to  be  rooted  in  a  fibrin-crasis,  whilst  florid  tuberculosis 
is  found  to  be  associated  with  a  deficiency  in  fibrin.  It  is  the  prevailing 
notion  of  mere  excess  in  fibrin  that  we  would  impugn. 

The  tuberculous-crasis  itself  may,  by  various  chances,  become  modified 


PYJEMIA —  PUS-BLOOD.  285 

through  a  combination  with  other  dyscrasial  constitutions  of  the  fluids, 
giving  rise,  at  least  in  part,  to  the  several  known  varieties  of  tubercle. 

The  tuberculous  crasis  is  commonly  protopathic.  Frequently  enough, 
however,  it  results  from  other  erases.  The  conversion  of  typhus,  of  ex- 
anthematous  hypinosis  to  the  tuberculo-croupous/crasis  is  frequent,  and 
of  the  greatest  scientific  and  practical  interest. 

The  tuberculous  crasis  results,  through  exhaustion  of  the  fibrin,  in  a 
defibrinated  condition  of  the  blood, — in  albuminosis.  And,  again,  the 
albumen — upon  which  the  wasted  fibrin  may  be  supposed  to  have  in- 
grafted its  own  morbid  character — may  take  up  the  work  of  exudation 
in  the  shape  of  acute,  albuminous  tubercle,  of  lardaceous  infiltration  of 
the  liver,  spleen,  and  kidneys, — of  general  albuminuria  ; — hydrgemia  and 
anaemia  being  the  final  issue. 

The  corpses  of  the  tuberculous,  responding  to  the  long-continued  and 
copious  expenditure  of  protein  substances  upon  tubercle,  present  general 
emaciation,  with  consumption  of  the  fat  and  of  the  bone-medulla ; — 
flabbiness,  wasting,  pallor  of  the  muscles ;  fatty  infiltration  of  the  liver, 
spleen,  and  kidneys ;  and  lastly,  oedema  and  dropsy.  The  blood,  with 
a  few  scanty  fibrinous  coagula,  is  fluid,  adhesive,  dark-red  ;  or  else,  with 
the  exception  of  very  inconsiderable  soft  coagula,  it  is  thin,  watery,  of 
a  pale-red,  resembling  water  in  which  flesh  has  been  steeped.  Wherever 
abundant  fibrin-coagula  are  met  with,  they  present  the  characters  proper 
to  the  fibrin-crasis,  often  in  conjunction  with  tubercle-like  concretions, 
which  in  their  elementary  composition  fully  harmonize  with  the  tubercle 
of  exudation,  that  is,  the  tubercle  of  the  textures. 

PY.EMIA.      PUS-BLOOD. 

This  crasis  again  represents  a  local  pus-production,  and  also  a  spon- 
taneous primitive  pyaemia  of  the  entire  blood-mass. 

In  pyaemia  it  is  necessary  to  distinguish  two  different  grades  or  stages, 
in  order  to  bring  the  various  facts  into  mutual  concord,  and  to  avoid 
contradiction  in  the  characteristic  given  of  this  blood  disease.  Those  facts 
are,  on  the  one  side,  the  coagulation  and  deposition ;  on  the  other  side, 
destruction,  of  the  fibrin.  The  latter  may  become  developed,  as  a  higher 
grade, — as  a  consecutive  stage,  out  of  the  former.  The  higher  grade 
may,  however,  set  in  at  once,  as  a  protopathic  crasis,  without  being  pre- 
ceded by  the  first  or  lesser  grade. 

In  the  lesser  grade  the  blood-crasis  is  characterized  by  quantitative 
excess  in  the  production  of  fibrin  [hyperinosis],  which  is  at  the  same  time 
qualitatively  impaired.  It  is  marked  by  a  high  degree  of  coagulability 
and  of  proneness  to  separation  from  the  blood-mass, — manifesting  itself  as 
croupous,  liquefying  fibrin.  These  main  features  of  the  crasis  illustrate 
the  following  appearances. 

The  fibrin-coagula  endogenous  to  the  vascular  system,  are  remarkable 
for  their  opacity,  for  their  varying  hues  of  dull  white,  of  yellowish-green, 
of  reddish-gray  [from  enclosed  blood].  They  are  soft,  and  yet  tough — 
their  contained  serum  being  of  a  whey-like  turbidness.  A  closer  inspec- 
tion shows  them  to  consist  of  a  glebous  basement,  with  the  rudiments  of 
fibrils,  and  about  these  a  vast  quantity  of  fine  point-molecule.  There 


286  PY^MIA  —  PUS-BLOOD. 

are,  besides  these,  nuclei,  and  nucleated  cells  the  nuclei  of  which  appear 
to  resemble  in  various  degrees,  up  to  complete  dissilience,  pus-nuclei. 
Sometimes  they  exhibit  little  tubercle-like  congeries,  which  consist  of 
collected  elements  of  pus.  Having  originated  during  life,  they  soften, 
with  liquefaction  of  the  said  basement,  to  a  fluid  which  assimilates  to  pus 
proportionately  to  the  amount  of  pus-cells  included  in  the  clot. 

This  crasis,  in  its  most  developed  grade,  possesses  the  peculiarity  of 
localizing  itself  in  many  areae  in  rapid  succession.  Along  with  highly 
acute  inflammation  with  purulent  effusion  upon  mucous  membranes,  upon 
serous  membranes,  and  in  areolar  tissue,  these  areae  appear  in  every 
variety  of  organ  and  of  texture,  and  are  generally  distinguished  for  their 
small  circumference  and  their  sharp  definition.  They  form  suddenly  in 
the  textures  as  red  obstructions,  which  almost  as  speedily  deliquesce 
with  sloughing  and  ulcerous  fusion  of  the  involved  textures  to  a  yellow 
or  greenish-yellow  pus.  Wherefore, — as  also  owing  to  the  lack  of 
evidence  of  antecedent  inflammation, — they  have  received  the  name 
of  pus  deposits  or  dep6ts ;  of  pus  metastases.  We  have  already  described 
the  attendant  anatomical  process,  and  seen  that  these  acts  [like  others 
brought  about  under  the  fibrin-erases]  consist  essentially  in  a  spontane- 
ous coagulation  of  the  blood-fibrin  in  the  capillaries,  and  its  immediate 
liquefaction,  with  ulcerous  corrosion  of  the  bloodvessel  membranes  and 
of  the  contiguous  textures ;  to  which  process,  inflammation  with  similar 
products,  as  the  encompassing  inflammatory  areola,  supervenes.  Coagula 
of  the  same  nature  form  in  the  great  vessels,  and,  in  the  shape  of  purulent 
vegetations,  also  in  the  heart. 

The  blood  appears,  along  with  the  endogenous  fibrin-coagula  described, 
as  a  tenacious  fluid  of  a  russet  hue.  It  is  seen  spread  out  in  a  thin  layer, 
and  mingled  with  little  soft  particles,  which  turn  out  to  be  aggregates 
of  pus-nuclei  and  pus-cells,  along  with  blood-corpuscles,  in  a  transparent 
clot. 

The  dead  body,  owing  to  the  voluminous  separation  of  coagula,  presents 
extensive  livid  patches  verging  upon  russet  coloration ;  hypostases :  tex- 
tural  redness  of  imbibition ;  lack  of  rigor ;  flabby  muscles ;  friable,  doughy, 
collapsed  parenchymata. 

The  higher  grades  of  the  pus-crasis  consist  in  destruction  of  the  fibrin  ; 
attenuation  and  discoloration  of  the  blood ;  septic  decomposition  of  the 
circulating  fluid,  of  a  nature  corresponding  to  the  rapid  ulcerous  and 
gangrenous  up-breaking  of  textures  in  the  local  processes. 

The  more  intense  is  the  aggravation  of  the  crasis,  the  less  do  we 
encounter  the  aforesaid  depots.  It  is  only  in  the  transition  to  the 
higher  grades  that  we  meet  with  them,  obviously  breaking  up,  along 
with  the  involved  textures,  to  a  dingy  brown,  coffee-ground,  or  olive- 
colored,  collapsing,  fetid  pulp.  The  same  metamorphosis  affects  both 
the  exudates  and  their  parent  strata.  In  the  highest  grade  extensive 
passive  stases  affect  the  decomposed  blood,  producing  necrosis  with  dark 
and  hemorrhagic  imbibition  of  the  textures. 

The  dead  bodies  of  persons  who  have  died  of  pyaemia  at  this  stage, 
manifest,  apart  from  the  external  and  internal  local  processes — due,  it 
may  be,  to  an  earlier  phase — long  retention  of  animal  warmth,  little 
and  evanescent  rigor,  flabby  and  pale  muscle,  more  especially  discolora- 


PYJ3MIA  —  PUS-BLOOD.  287 

tion  and  lacerability  of  the  heart,  and  rapid  decomposition  with  exten- 
sive, brownish  death-patches.  The  parenchymata  are  lax,  easily  torn, 
serum-drenched,  pale,  or  of  a  spurious  redness  in  various  shades,  owing 
to  hyperaemia  and  imbibition  of  dissolved  blood-pigment.  The  lungs 
are  the  especial  seat  of  hypostatic  congestion,  with  a  dark  coloration 
verging  upon  cherry-red  or  upon  brown.  The  blood  in  the  heart  and 
vascular  trunks  contains  scanty,  colloid-like,  cruor-holding,  red,  and 
sometimes  greenish-red,  coagula,  and  is  itself  of  a  cherry  red,  adhesive, 
or  else  attenuate,  brownish ;  having  stained  the  bloodvessel  membranes 
and  the  endocardium  with  its  coloring  matter.  Pyaemia  is  not  unfre- 
quently  primitive  [protopathic — or  deuteropathic,  that  is  arising  out  of 
other  anomalous  erases — for  example,  the  typhous,  the  exanthematous]. 
More  commonly,  however,  it  is  consecutive  to  the  reception  of  pus  into 
the  blood,  or  else  to  infection,  brought  about  in  the  various  ways,  fully 
detailed  at  page  274  of  the  present  volume. 

This  applies  to  both  grades  of  pyaemia  of  which  it  has  been  stated 
that  the  second  also  occurs  independently,  determined  through  infection 
of  the  blood  by  a  foul  pus  decomposed  through  stagnation.  To  this 
category  belongs,  amongst  others,  the  infection  proceeding  from  the 
poisoning  of  wounds  with  pus  out  of  the  dead  body.  Darcet  brought 
forth  the  disease  by  injecting  corrupt  pus-plasma,  a  disease  into  which, 
as  a  purulent  sepsis  or  necrosis  of  the  blood,  the  minor  grades  of  pyaemia 
with  hyperinosis  become  spontaneously  exalted,  probably  owing  to  the 
pus  in  the  blood  becoming  oxidized  in  the  respiratory  process. 

The  circumstance  that  pus  secreted  bodily  into  the  canal  of  a  blood- 
vessel, commonly  produces  a  more  intense  infection  than  pus-plasma 
probably  received  into  the  blood  by  resorption,  might  lead  one  to  con- 
clude that  it  is  to  the  pus-cell  that  pyaemia  is  attributable.  Nevertheless, 
apart  from  the  incomparably  larger  proportion  of  pus  received  into  the 
blood  in  the  former  case  than  in  the  latter,  the  occurrence  of  primitive 
pyaemia  precludes  our  adjudicating  in  favor  of  either  the  pus-cell  or  pus- 
plasma  as  the  causal  agent.  Far  more  depends,  without  any  doubt, 
upon  the  quality  of  the  pus ;  and  it  is  certain  that  a  large  proportion  of 
bland  pus  taken  up  into  the  circulation  proves  far  less  mischievous  than 
an  incomparably  smaller  quantity  of  purulent  ichor.  That  the  pus-cell 
taken  up  into  the  blood,  or  even  that  other  cell  formations  of  larger 
size — certain  cancer-cells,  for  example — should,  by  obstructing  the 
capillaries,  give  rise  mechanically  to  so-called  depots  [metastases]  will 
scarcely  be  credited  at  the  present  day. 

Pyaemia  generally  proves  fatal,  as  purulent  poisoning :  inconsiderable 
grades  of  it,  however,  are  susceptible  of  cure.  This  occurs,  without 
doubt,  partly  through  a  conversion  of  the  pus,  analogous  to  the  meta- 
morphosis of  fibrin — partly  through  elimination  of  the  pus  in  exudatory 
processes,  especially  upon  extensive  mucous  membranes,  like  that  of  the 
intestinal  tract.  The  elimination  of  pus  through  processes  of  secretion, 
for  instance,  its  passage  through  the  kidneys,  with  the  concurrent  dis- 
appearance of  pus-deposits,  is  a  phenomenon  much  talked  of.  The 
pus-cell  both  in  the  urine  and  in  exudates  is  incapable  of  becoming 
reabsorbed,  and  equally  so  of  passing  out  of  the  bloodvessels,  either 
into  the  uriniferous  tubules  or  at  any  other  part.  It  follows,  therefore, 


288  VENOSITY,     ALBUMINOSIS. 

that  pus-cells,  either  in  the  urine   or  in  an   exudate,  must  be  a  new 
creation  out  of  effused  plasma. 

2.   VENOSITY,  ALBUMINOSIS. — HYPINOSIS  (SIMON). 

This  constitution  of  the  blood  is  characterized  by  deficiency  in  fibrin 
but  preponderance  of  albumen,  and  generally  speaking,  also  of  blood- 
globules.  The  blood  is  upon  the  whole  thickish,  tenacious,  dark-red, 
and  contains,  if  any,  only  a  few  soft,  gluey  or  jelly-like  coagula,  in 
which  there  is  much  cruor  pent  up. 

It  has  a  very  extensive  domain,  comprising  a  vast  number  of  special 
erases,  which  reveal  their  kindred  nature  by  the  general  characters  of 
the  blood  just  defined,  by  the  metamorphoses  which  many  of  them 
undergo  in  common,  and  by  the  general  sameness  of  their  products  ; 
whilst  again  they  differ  in  some  particular  attribute  of  the  latter,  and 
by  specific  relations  to  particular  textures  and  organs  [localization]. 

Their  range  comprehends  the  most  important  and  most  perilous,  acute 
and  chronic  diseases ;  plethora  [general  hyperaemia],  venosity  of  the 
lungs,  and  heart  diseases,  the  acute  exanthemata,  especially  scarlatina 
and  measles,  the  so-called  substantive  fevers,  chronic  rheumatism  and 
gout,  rickets,  typhus,  Asiatic  cholera,  so-called  acute  tuberculosis, 
Bright's  disease,  and  lardaceous  degeneration  of  the  liver,  spleen,  or 
kidneys,  mollities  ossium,  cancer,  the  erases  of  acute  convulsions,  of 
tetanus,  of  hydrophobia,  diseases  of  the  nerve-centres,  chronic  mental 
alienation,  hypochondriasis,  chronic  metal-poisoning,  especially  with 
lead,  narcotism,  finally  the  erases  accompanying  atrophy  after  acute, 
exhausting  diseases,  the  so-called  suffocative  death-seizures  generally. 

To  discover  the  nature  of  the  special  crasis  in  so  heterogeneous 
states,  is  reserved  for  the  future,  and  rather  for  chemistry  than  for 
anatomy. 

Many  acute  erases  issue  in  septic  destruction  of  the  albumen  and 
putrid  decomposition  of  the  entire  blood-mass.  This  consummation  is 
especially  frequent  in  the  exanthematous  and  the  typhous  erases,  and  in 
acute  convulsions.  The  acute  erases  are  moreover  liable  to  frequent 
transformations,  especially  to  the  croupous  crasis  and  to  pyaemia.  There 
occurs  frequently  an  acidifying  of  the  blood,  which  localizes  itself  in 
miliary  eruption  and  in  acute  softening  of  the  stomach. 

The  crasis  is  sometimes  protopathic, — habitual,  persistent,  ingrained 
in  the  individual,  or  acute  and  evanescent.  At  other  times  it  is  deutero- 
pathic,  or  the  sequel  to  exhausting  and  especially  to  defibrinating 
disease.  It  is,  moreover,  a  primitive  blood-disease,  called  forth  by 
poisons,  by  miasma,  by  contagion,  or  else  it  is  consecutive  to  disease  of 
solid  parts  [for  example,  organic  heart  disease],  and  determined  by 
neurosis. 

The  products  placed  under  its  control  [exudates  and  new  growths] 
are  distinguished  by  an  excess  of  albumen,  by  very  subordinate  coagu- 
lability, by  lack  of  disposition  to  become  organized,  by  persistence  at 
embryonic  grades  of  structural  development. 

A  not  unfrequent  sequel  to  extensive  exudation  is  hydrasmia,  or,  it 
may  be,  tarlike  inspissation  of  the  blood  with  anaemia.  The  former 


TYPHUS-CRASIS.  289 

becomes  developed  without  any  notable  serous  effusion,  the  water  being 
otherwise  disposed  of  in  the  morbid  process.  The  anaemia  is  commonly 
due  to  a  shattered  condition  of  the  nervous  system. 

Several  of  these  acute  erases  have  a  decided  relation  to  the  mucous 
membranes,  and  especially  to  their  follicular  apparatus,  to  the  lymphatic 
glandular  system,  to  the  common  integuments,  to  the  spleen.  The  dead 
body  presents,  especially  in  the  acute  erases,  dark  coloration  of  the 
common  integument ;  rapidly  developed,  extensive,  and  very  dark  death- 
patches  ;  early  decomposition ;  a  very  marked  but  for  the  most  part 
evanescent  rigor,  and  a  lax,  doughy  condition  of  the  parenchymata. 
Hypersemise  and  stases  arising  in  the  different  organs,  not  unfrequently 
become  exalted  into  hemorrhage.  In  the  tarlike  inspissation  of  the  blood, 
the  corpse  is  in  a  high  degree  emaciated  or  rather  shrunken,  dry, — the 
common  integument,  of  a  lead-color,  or  livid. 

Let  us  endeavor  to  submit  the  more  important  of  these  erases  either 
singly,  or  where  the  distinctions  are  not  very  marked,  more  collectively, 
to  an  anatomical  muster. 

(a.)   PLETHORA. 

It  is  characterized  by  excess  of  blood,  by  a  preponderance  of  the  blood- 
globules  over  the  fibrin,  by  a  deep  red,  tenacious  blood.  It  involves  the 
direct  manifestations  of  venosity  in  the  inverse  ratio  of  the  amount  of 
blood  which  the  organism  is  capable  of  arterializing.  It  occurs  under 
two  opposite  and  contrasting  relations.  First,  in  conjunction  with  florid 
nutrition  of  the  textures,  fulness  of  muscle,  and  especially  ample  areolar 
tissue  and  fat  formation.  Secondly,  as  a  very  marked  phenomenon  in 
union  with  general  emaciation, — wasting  of  the  solids  [so-called  nervous 
tabes].  Under  the  latter  circumstances,  it  is  observable  both  in  very 
delicate  children,  during  the  first  months  of  their  life,  and  in  insane  adults 
[in  hypochondriasis,  melancholia,  &c.] 

In  the  dead  body,  the  general  overloading  of  the  vascular  system,  and 
occasionally  surpassing  hypersemia  of  various  organs,  especially  of  the 
lungs  or  of  the  brain,  or  of  the  liver  and  entire  portal  system,  are  mani- 
fest. According  to  the  degree  of  intensity  of  the  crasis,  all  of  the  soft 
parts  are  more  or  less  deeply  colored.  In  the  emaciated,  the  common 
integuments  exhibit  vast  patches  of  a  purple,  or  of  a  bluish  leaden  hue. 

Plethora  predisposes  to  congestion,  to  hemorrhage,  to  blennorhoid, 
albuminous,  and  serous  exudations  of  greater  or  less  moment  in  propor- 
tion to  their  amount  and  to  the  importance  of  the  organs  concerned.  In 
corpulent,  square-built  [apoplectic]  individuals  hypersemise  of  the  lungs 
are  frequent.  In  these  the  plethora  often  of  itself,  but  more  commonly 
through  acute  serous  effusion  into  the  bronchia  and  lung-cells,  proves 
speedily  fatal.  Moreover,  the  plethora  occasions  dilatation  of  the  heart, 
with  subsequent,  progressive  augmentation  of  its  substance  [hyper- 
trophy]. 

(b.)   THE   TYPHUS-CRASIS. 

It  compasses  the  entire  nature  of  typhous  disease,  and  is  at  the  root  of 
all  its  phenomena,  whether  of  substantive  change  or  of  functional  dis- 
turbance. 

VOL.    I.  19 


290  TYPHUS-CRASIS. 

The  typhus-crasis  is  marked  by  the  destruction — the  diminution — of 
the  fibrin,  and  the  comparative  preponderance  of  the  blood-globules. 
The  typhus  blood  is  in  various  degrees  fluid,  and  of  a  deep  purple  color. 
It  forms,  if  any,  but  scanty,  loose,  soft,  and  humid,  deliquescent  coagula, 
reddened  by  the  imbibition  of  pigment-holding  plasma. 

The  corpses  of  typhous  individuals  are  remarkable  for  the  deep,  dingy, 
bluish-gray  coloration  of  the  common  integument,  for  the  deep  purple  of 
the  death-spots,  for  the  dark  russet  hue  and  the  rigidity  of  the  muscles, 
and  for  the  dryness  of  the  areolar  tissue.  The  serous  membranes,  and 
especially  the  peritoneum  are  of  a  dull  gray,  lack-lustre,  and  occasionally 
suffused  with  a  tenacious  humor.  All  the  textures  in  contact  with  blood 
appear  discolored  from  imbibed  hsematin,  of  a  peculiar  shade,  verging 
from  violet  color  upon  brown. 

In  the  next  place,  the  multifarious  local  hypersemise  have  to  be  noticed. 
They  are  due  to  the  paralyzing  influence  of  the  blood  upon  determinate 
ranges  of  the  nervous  system,  either  at  the  periphery  or  at  the  centres. 
Foremost  amongst  them  are  local  hypergemise  of  the  mucous  membranes, 
of  the  lungs,  of  the  brain,  and  its  membranes,  of  the  spinal  cord,  of  the 
common  integuments.  They  often  display  the  attributes  of  so-called 
hypostasis.  Upon  mucous  membranes  they  frequently  degenerate  into 
hemorrhages,  which  occur  also,  although  far  more  rarely,  in  parenchymata, 
for  example,  in  the  brain. 

The  typhus-crasis  manifests  a  very  marked  relation  to  mucous  mem- 
branes, especially  to  the  lymphatic  glartds  and  to  the  spleen.  In  middle 
Europe  it  is  the  mucous  membrane  of  the  intestine  and  especially  of  the 
ileum,  rarely  the  bronchial  mucous  membrane  with  the  lungs  and  the 
bronchial  glands ;  in  the  North,  it  is  rather  the  last  mentioned,  namely, 
the  respiratory  tract ;  in  the  South  [in  pest-typhus],  it  is  the  peripheral 
lymphatic  gland  system,  in  which  the  crasis  becomes  localized.  In  the 
form  of  a  typhous  inflammation  it  determines,  in  the  follicular  apparatus 
of  the  ileum  and  in  the  mesenteric  glands,  a  peculiar  marrow-like  product, 
which,  in  intense  cases,  closely  resembles  medullary  carcinoma. 

The  very  variable  consistency  of  the  typhus-substance  points  to  varia- 
tions in  the  typhus-crasis  itself;  to  different  degrees  of  plasticity  in  the 
typhous  blood-plasma. 

Pus-formation,  we  have  to  observe,  is  alien  to  the  genuine  typhous 
process  whether  general  or  local.  Wherever  it  does  occur,  it  is  founded 
in  a  degeneration  or  change  in  the  typhus-crasis,  of  which  we  have  to  say 
a  few  words.  No  other  crasis  offers  such  manifold  interest  in  reference 
to  degeneration  or  conversion.  Not  alone  are  there  several  conversions  of 
the  kind,  but  they  are  remarkable  for  an  impress  the  exact  reverse  of  the 
original  typhus.  The  recognition  of  these  phases  and  their  interpreta- 
tion as  degenerations  or  transformations,  are  not  only  of  the  greatest 
scientific  interest,  but  also  of  the  most  obvious  practical  utility.  These 
changes  resolve  themselves  into  the  following.  They  are  more  or  less 
demonstrable  in  the  sanguineous  fluid,  as  also  more  or  less  proclaimed  in 
corresponding  local  processes. 

1.  Conversion  to  the  croupous  crasis. 

2.  Conversion  to  pyaemia. 

3.  Degeneration  to  acute  softening  [acidification  of  the  blood]. 

4.  Degeneration  to  gangrene  [Sepsis, — necrosis  of  the  blood]. 


TYPHUS-CRASIS.  291 

1.  Conversion  to  the  croupous  crasis.     A  fibrin  of  a  constitution  cha- 
racteristic of  the  croupous  erases  forms  in  the  blood.    Perishable  coagula 
[vegetations,  plugging  clots,  so-called  capillary  phlebitoids]  originate  in 
the  heart,  in  the  greater  vessels,  in  the  capillaries ;  but,  above  all,  exu- 
dative processes,  upon  mucous  membranes.     Those  croupous  inflamma- 
tions of  the  mucous  membrane  lining  the  trachea!  canal,  the  oesophagus, 
the  stomach  and  intestines,  the  female  sexual  organs,  as  also  croupous 
pneumonia,  all  belong  to  this  type.    Again,  similar  processes  upon  serous 
membranes,  the   yellow,  fibrinous,  crumbling   products  by  which  the 
typhous  infiltrations  of  the  mesenteric  and  Peyerian  glands  are  modified. 

*  The  exudates  are  wont  to  exert  a  solvent  influence  upon  their  parent 
strata,  deep  corrosions  of  the  mucous  membranes  beneath  the  exudates, 
more  especially  at  the  glottis  and  epiglottis,  being  not  at  all  uncommon. 

This  conversion  takes  place  at  various  periods  of  the  typhous  process — 
even  at  a  very  early  stage.  It  is  deserving  of  notice  that  a  vast  number 
of  cases  in  point  happen  at  the  commencement  of  epidemics  of  cholera, 
a  disease  in  whose  typhoid  [so-called  reaction-]  stage  croupous  inflamma- 
tions are  so  frequent.  [See  " Exanthematous  Crasis."] 

The  conversion  of  the  typhus-crasis  to  the  tuberculous — the  tuberculo- 
croupom — crasis  belongs  to  the  same  class.  Its  localization  generally 
attaches  to  the  lungs  in  the  shape  of  lobular — not  unfrequently  of  a 
comprehensive  lobar  pneumonia ; — pneumonic  tubercle-infiltration. 

2.  A  second  conversion  of  the  typhus-crasis,  kindred  with  the  preceding 
one,  is  that  to  pyaemia  and  local  pus  production.    It  occurs,  for  the  most 
part,  at  a  later  period  than  the  one  just  referred  to,  often  complicating  the 
last  stage  of  the  local  typhus-process  upon  the  mucous  membrane  of  the 
ileum,  and  protracting  itself  into  a  sequela  to  the  typhus.     Examples 
hereof  are  the  pus-deposits  in  the  typhous  patches  upon  the  mucous  mem- 
brane of  the  ileum,  and  in  the  infiltrated  mesenteric  glands ;  the  pus- 
producing   areolar-tissue  inflammations ;    the   purulent  exudates  upon 
serous  tunics ;  the  circumscript,  suppurating  coagulations  in  the  capillary 
system  of  the  lungs,  the  spleen,  the  kidneys ;  the  boil-like  obstructions 
of  the  capillaries  in  the  substance  of  the  mucous  membranes  and  of  the 
outer  skin. 

3.  Degeneration  to  the  acute  softening  process,  that  is,  to  a  crasis  in 
which  the  latter  is  founded,  and  which  is  localized  in  softening  of  the 
stomach,  &c.     We  believe  this  process  to  be  a  peculiar  one,  quite  distinct 
from  putrid  decomposition  and  its  characteristic,  gangrenous  sloughings. 
That  which  concerns  us  here  occurs  as  black,   or  Indian  ink-colored 
softenings  or  meltings  of  the  textures  in  an  acid  fluid,  especially  in  the 
coecal  sac  of  the  stomach,  on  the  left  side  of  the  oesophagus,  in  the  lungs, 
upon  the  mucous  membrane  of  the  ccecum,  and  in  the  urinary  bladder. 

"We  believe  this  process  to  be  derived  from  the  blood  in  the  capillaries 
of  the  parts  referred  to,  and  to  be  due  to  an  acidification  of  the  blood- 
mass, — to  the  presence  of  a  free  acid  in  the  blood: 

(a.)  It  is  developed  out  of  a  hypersemia  and  stasis  in  the  implicated 
organs,  and  in  point  of  fact,  out  of  the  blood  engaged  in  the  stasis,  which 
experiences  the  first  effect  of  the  liberated  acid  upon  itself,  in  the  shape 
of  inspissationand  coagulation  to  a  black,  pitch-like,  friable  mass,  destruc- 
tive of  the  walls  of  the  vessels  and  of  other  contiguous  textures. 


292  EXANTHEMATOUS    CRASIS. 

(b.)  The  reaction  of  the  structures  softened  is  invariably  acid. 

(c.)  Our  view  seems  to  derive  support  from  the  determination  of  the 
blood  under  these  circumstances  to  the  coecal  sac  of  the  stomach,  which, 
with  the  spleen,  appears  to  us  to  perform  the  office  of  a  de-acidifying 
apparatus  to  the  blood-mass,  for  the  immediate  secretion  of  the  gastric 
juice  and  in  behalf  of  the  hepatic  function. 

(d.)  A  very  frequent  appearance  associated  with  the  impending  soft- 
ening, is  that  of  a  miliary  eruption  with  acid  reaction  of  the  contents  of 
the  vesicles. 

4.  Degeneration  to  sepsis  ;  putrid-crasis.  Primary  gangrene  of  the 
solids.  It  occurs  either  very  early,  or  only  as  a  sequel  to  typhus. 

The  blood  and  the  dead  body  exhibit  the  peculiar  changes  to  be 
described  in  another  place. 

Where  the  putrid  character,  is  early  developed,  the  faint  impression  in 
its  localization,  especially  with  respect  to  plasticity  of  its  products,  is 
remarkable.  The  Peyerian  gland-groups  are  turgid  with  sero-albumi- 
nous  infiltration,  lax,  and,  together  with  the  mucous  membrane  of  the 
ileum,  generally  ecchymosed. 

As  the  local  manifestation  of  this  degenerate  state,  sloughing  takes 
place  in  parts  exposed  to  hypostasis  and  pressure,  for  instance,  in  the 
sacral  region,  at  the  trochanters,  &c.  This  is  not  all,  however :  hyperae- 
miae  and  stases  become  developed  even  in  parts  beyond  the  range  of 
hypostasis,  leading  incontinently  to  mortification  of  the  textures, — for 
example  noma  of  the  cheeks,  sphacelus  of  the  external  sexual  organs  in 
the  female. 

All  these  degenerations  may  become  localized  in  the  typhus-ulcers, 
leading,  as  will  be  seen,  in  the  account  given  [see  vol.  ii.]  of  the  local 
typhus-process  in  the  intestinal  membrane,  to  a  destruction  overstep- 
ping the  limits  of  the  textures,  and  frequently  to  perforation  of  the  intes- 
tine. 

Other  sequelae  of  the  typhus-crasis  are  protracted  albuminuria  [Bright's 
disease],  anaemia  [with  wasting],  hydrsemia  [(Edema,  Dropsy]. 


(<?.)   THE   EXANTHEMATOUS   CRASIS. 

Its  domain,  viewed  from  the  anatomical  side  is  a  very  extensive  one. 
However,  we  might  wish  to  limit  this  crasis  to  scarlatina  and  measles,  a 
number  of  acute  blood  diseases  naturally  cluster  around  them,  become 
localized  upon  the  greater  mucous  membranes,  and  not  unfrequently, 
especially  in  epidemics,  produce  exanthemata  presenting  more  or  less 
analogy  with  genuine  measles,  or  pure  scarlatina.  Amongst  them  are 
some  which  determine  a  more  or  less  plastic,  albumen-loaded,  coagula- 
ting or  colloid-like,  thinly  purulent,  almost  serous  product  upon  mucous 
membranes ;  exudatory  processes  which  bring  the  muco-membranous 
texture  into  a  state  of  dissolution;  Asiatic  cholera;  numerous  puerperal 
affections ;  acute  diarrhoea,  especially  in  children ;  nay,  even  exanthema- 
tous  typhus  ;  in  fine,  many  substantive  [exanthematous]  fevers  without 
exanthema.  At  the  uttermost  limits  of  this  domain  are  placed  blood 
diseases,  associated  with  tonic  spasm  and  convulsions, — with  affections 


EXANTHEMATOUS    CRASIS.  293 

of  the  nervous  centres.  Last  of  all,  acute  tuberculosis.  In  the  pre- 
sent section,  however,  we  shall  only  speak  of  the  exanthematous  crasis 
and  of  those  nearest  allied  to  it,  leaving  the  remainder  to  be  discussed 
in  separate  chapters.  The  crasis  in  question  is  the  most  distinctly 
marked  in  scarlatina ;  and  it  is  here  that  we  have  the  best  opportunities 
for  studying  it  in  the  dead  body.  In  degree,  the  crasis  of  measles  is 
perhaps  nearly  the  same,  as  are  also  the  blood  diseases  already  stated  to 
follow  next  in  the  scale. 

Upon  the  whole,  the  exanthematous  crasis  has  the  greatest  affinity  to 
the  typhous.  Only  the  blood  is  still  more  fluid,  whilst  the  violet  tint 
present  in  intense  typhus  is  wanting.  The  blood  verges  more  upon  pur- 
ple,— upon  cherry-red. 

The  dead  body  manifests  a  certain  degree  of  turgor.  There  is  a  lack 
of  that  tenseness  of  the  muscles,  and  of  the  common  integument,  as  also  of 
the  dingy-gray  coloration  of  the  latter.  The  skin  is  indeed  rather  white, 
although  with  extensive,  very  saturated  death-patches.  The  serous  mem- 
branes very  often  exhibit  a  viscid,  ropy,  colorless  covering.  Local  hy- 
peraemiae,  partly  of  hypostatic  nature,  and  imbibition  of  the  textures  with 
blood-pigment,  are  observable. 

Along  with  these  differential  points,  and  apart  from  the  resemblance 
in  the  anatomical  characters  of  the  blood,  special  analogies  come  forth 
between  the  typhous  and  the  exanthematous  crasis.  Such  as : 

(a.)  The  relation  of  the  exanthematous  crasis  to  the  mucous  mem- 
branes, and  also  to  the  lymphatic  glands.  It  is  expressed  in  the  well- 
known  catarrhal,  erythematous,  and  other  affections  of  the  respiratory 
and  gastro-enteric  tracts  of  mucous  membrane  ; — in  the  well-known  en- 
largements of  peripherous  lymphatic  glands  accompanying  the  course  of 
the  exanthemata.  What  is,  however,  particularly  characteristic,  is  the 
development  of  the  follicle  apparatus  of  the  ileum  and  of  the  mesenteric 
glands  in  scarlatina,  and  in  the  entire  series  of  analogous  blood  diseases. 

(b.)  The  identical  conversions  of  the  crasis  observed  in  typhus.  The 
most  frequent  are  the  conversion  to  the  croupous  crasis,  including  the 
tuberculo-croupous,  with  corresponding  local  products,  and  the  often 
early  degeneration  to  putrid  decomposition. 

Among  the  sequelae  there  is  one  proper  to  typhus,  and  also  a  very 
frequent  consequence  of  scarlatina, — namely,  protracted  albuminuria. 

Another  consequence  of  the  exanthematous  processes,  is  intense  inspis- 
sation  of  the  blood,  with  marked  hyperaemiae  and  stases. 

As  far  as  its  crasial  source  is  concerned,  variola  does  not  seem  to  con- 
stitute an  exception.  It  is,  however,  essentially  obnoxious  to  a  speedy 
transition  into  the  croupous-crasis  and  into  pyaemia,  the  latter  often  out- 
running its  normal  term.  In  common  with  the  exanthematous  crasis 
generally,  it  is  liable  to  degenerate  early  into  putrid  decomposition, 
which,  anticipating  the  croupous  and  the  pyaemic  phases,  precludes  the 
formation  of  any  products  due  to  these  modifications  of  the  exanthema, 
and  causes  the  pocks  to  degenerate  into  the  so-called  putrid. 

Amongst  the  diseases  following  closely  in  the  wake  of  the  more  promi- 
nent exanthemata,  the  under-mentioned  are  peculiarly  deserving  of  notice, 
namely : 

A  large  proportion  of  puerperal  fevers — especially  when  bearing  an 


294  EXANTHEMATOUS    CRASIS. 

epidemic  impress.  The  characters  presented  by  the  dead  body,  and  the 
anatomical  relations  of  the  blood,  answer  to  the  exanthematous  crasis  ; 
to  which  may  be  added,  the  presence  of  the  exudatory  processes  above 
specified  upon  the  uterine  mucous  membrane,  the  character  of  exudates 
detected  upon  the  serous  membranes,  especially  the  peritoneum,  and 
finally,  the  frequency  of  concurrent  exanthema,  in  the  shape  of  ery- 
thema and  of  scarlatina.  These  puerperal  processes  are  marked  by  their 
tendency  either  to  become  converted  into  the  croupous  crasis,  or  else  to 
degenerate  into  putrid  decomposition.  Nor  is  acute  softening  of  the 
stomach  a  rare  coincident  phenomenon. 

A  crasis  appertaining  to  this  class  often  becomes  localized,  as  one  of 
the  exudatory  processes  adverted  to,  uponthe  intestinal  mucous  membrane, 
as  in  many  instances  of  acute  diarrhoea  and  of  dysentery.  These  often 
prove  fatal  through  paralysis  of  the  intestine — through  exhaustion.  A 
very  remarkable  and  momentous  phenomena,  however,  is  a  resulting 
thickening  of  the  blood  to  a  dark  red  liquid,  of  a  tarry  appearance,  and 
of  the  consistency  of  treacle.  It  proves  fatal  under  the  symptoms  of 
anaemia  in  vital  organs  [lungs,  brain],  of  rigor  [tonic  spasm]  of  muscular 
organs,  or  else  through  local  hypersemiaa  [for  example  of  the  brain]. 
Eruptive  phenomena  in  the  progress  of  the  dysenteries  are  not  at  all 
uncommon. 

Conversions  of  the  crasis  to  the  croupous  and  to  protracted  pyaemia 
are  frequent.  % 

Next  in  the  series  is  the  cholera-process.  It  is  a  more  or  less  rapidly 
developed  hypinosis,  with  the  characters  of  the  exanthematous.  Its 
localization  extends  over  the  entire  intestinal  tract  as  an  exhausting  exu- 
datory process,  multifarious  in  its  products,  and  either  proving  rapidly 
fatal  under  acute  inspissation  of  the  blood  and  the  aforesaid  contingent 
phenomena,  or  else  passing  over  into  a  so-called  stage  of  reaction. 

In  the  former  case,  the  dead  subject  presents  a  dingy,  blue-gray  colora- 
tion of  the  common  integument — a  puckered  state  of  the  latter  and  of 
the  areolar  tissue,  with  herb-like  dryness  and  rigidity,  and  with  dark 
coloration  of  the  muscles.  The  blood,  if  we  except  certain  stases  in  dif- 
ferent ranges  of  the  vascular  system,  especially  in  the  bloodvessels  of 
the  membranes  of  the  brain,  is  found  acccumulated  in  the  vascular 
trunks,  and  in  the  heart,  as  a  dark  tar-like  mass,  without  fibrin-coagu- 
lum.  The  lungs  are  for  the  most  part  dry,  inflated,  of  a  deep  red  ;  the 
serous  membranes — more  especially  the  peritoneum — moistened  with  an 
abundant  viscid  coating.  The  intestinal  canal  is  the  seat  of  an  exten- 
sive, and  equally  rapid  and  intense  process  of  exudation,  and  presents 
the  general  lineaments  of  paralysis.  Surcharged  as  it  is  with  fluid,  it 
is  nevertheless  collapsed,  soft,  and  flabby-membraned,  pallid,  rarely  pre- 
senting any  intussusception.  It  contains,  in  varied  measure,  a  serous 
fluid,  rendered  turbid,  whey-  or  rice-water-like,  whitish  or  yellowish- 
white,  by  the  debris  of  epithelium  and  minute  particles  of  protein  sub- 
stances, or  else  slightly  reddened  by  the  intermingling  of  blood.  The 
mucous  membrane  is  denuded  of  its  epithelium,  and  bare ;  or  the  coagu- 
lable  portion  of  the  exudation  may  adhere  to  it  in  the  shape  of  a  loose 
bran-like  covering,  or  of  membrane-like  formations.  Its  texture  is 
bloated,  and  is  for  the  most  part  readily  scraped  oft7,  as  a  reddish-white 


DRUNKARD'S   DYSCRASIS.  295 

pulp ;  its  follicles,  especially  at  the  ileum,  distended  by  exudate  to 
the  bigness  of  millet  or  hemp-seeds.  The  spleen  is  shrivelled,  the  uri- 
nary bladder  empty.  In  the  ganglia  of  the  sympathetic  we  detect  little 
hemorrhagic  spots,  as  big  as  a  poppy  or  millet-seed. 

In  the  so-called  stage  of  reaction,  the  crasis  reverts  to  the  normal,  or 
else  the  hypinosis  changes  under  expansion  of  the  blood  into  a  typhoid 
disease.  The  latter  is  remarkable  for  a  secondary  localization  upon  the 
mucous  membrane  of  the  intestines,  in  the  shape  of  repeated  processes 
of  exudation,  and  also  for  exanthematous  processes  simulating  measles, 
scarlatina,  pemphigus  or  erysipelas,  upon  the  common  integument. 
During  the  thus  protracted  course  of  this  hypinosis,  it  is  very  usual  for 
a  fibrino  croupous  crasis  to  develope  itself,  and  for  the  mucous  membrane 
of  the  intestine,  of  the  stomach,  of  the  oesophagus,  of  the  trachea,  to 
display  croupous  exudation, — the  lungs,  croupous  pneumonia. 

This  hypinosis  is  moreover  convertible  to  pyaemia,  to  acute  softening, 
and  also  liable  to  putrid  decomposition. 

(d.)   HYPINOSIS   IN   DISEASES   OF   THE   NERVES. 

The  similarity  of  the  crasis  in  this  class  of  diseases  with  the  typhous 
and  exanthematous  erases  is  very  striking.  It  even  partakes,  in  com- 
mon with  these,  of  a  proneness  to  localize  itself  upon  the  intestinal 
mucous  membrane  in  the  follicular  apparatus  of  the  ileum, — in  a  turges- 
cence  [product-formation]  of  the  Peyerian  and  solitary  gland  capsules. 

To  this  category  belong  diseases  with  obvious  anatomical  disturbance 
in  the  nervous  centres,  and  again  diseases  in  which  such  disturbance  is 
either  wanting  or  subordinate  and  consecutive.  Such  are  meningitis, 
acute  hydrocephalus,  apoplexy,  and  the  like;  and  again,  acute  tonic 
spasm  and  convulsions,  tetanus,  trismus,  puerperal  convulsions,  pro- 
tracted epileptic  convulsions,  £c. ;  lastly,  hydrophobia. 

In  the  latter  diseases,  more  especially,  in  which  up  to  the  present  day, 
no  anatomical  disturbance  is  demonstrable,  the  question  arises  as  to 
whether  the  nervous  system  be  substantially  impaired  at  all, — whether 
the  anomaly  in  the  crasis  be  not  the  primary  cause  of  the  nervous  phe- 
nomena. 

It  appears  to  us  that,  although  the  most  accurate  examination  may  be 
inadequate  to  prove  any  palpable  anatomical  disturbance,  a  primitive 
affection  of  the  nervous  system  must  nevertheless  exist,  and  be  that 
which  determines  the  [secondary]  anomaly  of  the  crasis. 

This  crasis  not  unfrequently  degenerates  into  putrid  decomposition. 
It  often  becomes  converted  into  pyaemia,  and  not  unfrequently  issues  in 
acute  softening. 

In  fine,  those  rapidly  destructive  liquefactions  of  the  blood  may  be 
here  classified,  which,  under  the  name  of  asphyxia  furnish  forth  the 
majority  of  instances  of  sudden  death,  commonly  through  hypersemia 
of  the  lungs  with  acutely  developed  pulmonary  oedema. 

(e.)  THE  DRUNKARD'S  DYSCRASIS. 

That  dyscrasial  condition  induced  by  the  abuse  of  alcoholic  drinks, 
and  especially  of  gin,  occurs  under  two  forms,  differing  in  the  course 


296  DRUNKARD'S  DYSCRASIS. 

which  they  run — in  other  words,  there  is  a  chronic  and  also  an  acute 
drunkard's  dyscrasis. 

The  first,  namely,  the  chronic  crasis,  manifests  itself  as  plethora,  with 
a  remarkably  dark  coloration,  a  thickness  and  a  simultaneous  fattiness 
of  the  blood.  This  occasions,  and  at  the  same  time  accounts  for,  the 
condition  in  which  we  find  the  solids. 

The  pigmented  appearance  of  the  skin,  the  excessive,  and,  at  the  same 
time,  anomalous  fat-formation,  and  blennorrhoese,  are  all  characteristic 
of  the  crasis.  The  corpses  of  inveterate  dram-drinkers  present  very 
marked  appearances.  The  skii)  is  tinged  of  a  dingy  brown,  and  this  is 
coupled  with  the  fact,  that  not  unfrequently  parts  naturally  rich  in  pig- 
ment— the  scrotum,  for  example,  become  deprived  of  it.  At  the  same 
time  the  skin  is  of  a  soft,  unctuous  feel,  like  that  of  the  negro,  and  its 
epidermis  layer  is  thin.  Subjacent  to  the  skin,  and  also  in  the  mesen- 
tery and  the  omenta  is  deposited  fat,  in  an  excess  if  not  absolute,  at 
least  relative  to  the  state  in  which  we  find  the  muscles,  and  possessing  a 
peculiar  character  not  unlike  that  of  mutton  suet.  Together  with  this, 
the  muscle-flesh  appears  to  have  lost  in  volume,  and  to  have  become 
pallid.  The  fat-formation  steals  into  the  muscles  in  the  shape  of  fatty 
conversion.  The  liver  has  undergone  fatty  degeneration.  Even  in  the 
bones  the  fat  formation  has  gained  ground  at  the  expense  of  the  bony 
texture. 

All  the  mucous  membranes,  but  especially  the  bronchial  and  intesti- 
nal, are  affected  with  chronic  thickenhig  and  with  blennorrhoea,  the 
chronic  gastric  catarrh  [gastric  irritation]  being  particularly  marked.  A 
similar  state  of  hypertrophy  presents  itself  in  the  habitually  congested 
cerebral  membranes,  in  the  form  of  dulness,  thickening,  chronic  oedema. 

The  brain  is  affected  with  an  atrophy  like  that  met  with  in  the  aged, 
with  or  without  considerable  dilatation  of,  and  serous  effusion  into,  the 
ventricles. 

The  blood  appears  dark-colored,  grumous,  defibrinated,  viscid-unctuous 
to  the  touch,  often  intermingled  with  fat  in  large  quantity,  as  fat-drops. 
In  rare  instances  the  disease  occasions  a  chyle-like  opacity  of  the  plasma 
— milky  blood. 

The  chronic  drunkard's  crasis  often  undergoes  conversion  to  fibrin- 
erases  of  various  kinds.  Amongst  these  are  inflammations  with  fibrin- 
products,  even  tubercle.  Pneumonia  is  a  very  frequent  and  very  fatal 
disease  with  drunkards — pneumonia  running  an  acute  course,  and  pos- 
sessing an  eminently  croupous  character.  Chronic  hepatitis,  determin- 
ing organizable  products,  and  leading  eventually  to  liver-cirrhosis 
[granulation],  is  a  very  common  termination. 

In  drunkards  tuberculosis  runs  an  eminently  chronic  course.  The 
deposition  of  tubercle  is  for  the  most  part  inconsiderable  ;  the  granula- 
tions are  generally  of  a  dingy,  or  a  greenish-gray,  and  do  not  soften  as 
such.  The  yellow  tubercle  and  resulting  phthisis  are  more  rare. 

The  natural  issue  of  the  drunkard's  crasis  is  in  eventual  hydrsemia — 
in  dropsy — which  assumes  a  local  form,  especially  that  of  ascites,  the 
more  speedily,  the  earlier  heart-disease  or  liver-cirrhosis  becomes 
established. 

The  acute  crasis  has  a  marked  resemblance  with  the  exantheinatous, 


ACUTE    TUBERCLE-CRASIS.  297 

and  with  the  crasis  in  nervous  affections.  The  liquefaction  with  discolo- 
ration of  the  blood  and,  as  a  consequence  thereof,  the  tendency  to 
transudation  of  blood-serum,  are  for  the  most  part  more  developed.  The 
fat  is  wont  to  separate  from  the  blood  in  the  form  of  largish  drops. 

The  corpses  present  extensive,  very  saturated  death-patches  ;  evanes- 
cent rigor  of  the  dark  red  muscles ;  congestion  of  the  cerebral  mem- 
branes, and  still  more  of  the  lungs,  especially  as  hypostasis ;  scattered 
patches  of  stasis  in  the  intestinal  mucous  membrane,  £c.  The  paren- 
chymata  are  lax ;  those  affected  with  hyperaemia,  imbibed  with  a  colored 
blood-serum.  In  the  cavities  of  the  serous  membranes — more  especially 
of  the  pleura — are  dingy-red,  serous  [spurious  hemorrhagic]  effusions. 
The  corpses  emit  a  peculiar  sweetish  smell,  and  pass  rapidly  into  decom- 
position under  gas  development. 

The  inflammatory  stases  developed  during  the  progress  of  this  crasis 
are,  for  the  most  part,'thypostatic  pneumonise.  They  determine  a  pro- 
duct dark-colored  from  adherent  hgematin,  lax,  soft,  incompetent  to 
hepatize  the  lung-texture. 

This  crasis  never  becomes  developed  in  aged  persons  broken  down  by 
repeated  attacks  of  delirium  tremens,  but  invariably  in  drunkards  in  the 
early  years  of  manhood,  who  are  endowed  with  a  powerful  muscular 
system.  It  runs  a  very  rapid  course,  leading,  in  a  very  few  days  to  de- 
composition. 

We  are  aware  of  no  instance  of  this  crasis  passing  into  the  fibrin ous 
crasis,  or  into  pyaemia.  On  the  other  hand,  it  often  becomes  exalted 
into  decomposition,  and  not  unfrequently  issues  in  softening  of  the 
stomach. 

It  is  not  improbable  that  this  crasis  is,  in  the  majority  of  cases,  due 
to  injury  sustained  by  the  brain  during  a  violent  or  protracted  fit  of  in- 
toxication, and  that  it  ought  rather  to  have  found  a  place  in  the  pre- 
ceding chapter.  It  is  not  in  aged  drunkards,  with  an  atrophied  brain, 
that  it  occurs,  but  in  younger  individuals  with  a  brain  of  normal  de- 
velopment, keenly  sentient  of  congestion,  and  of  an  alcoholized  condition 
of  the  blood. 

(/.)  THE  CRASIS  OF  ACUTE  TUBERCULOSIS. 

This  crasis  has  the  greatest  resemblance  with  the  exanthematous,  and 
the  disease  assimilates  so  closely  in  its  manifestations  during  life  to 
typhus  [intestinal  typhus],  as  only  to  be  distinguishable  from  the  latter 
by  the  absence  of  abdominal  symptoms,  the  more  marked  phenomena 
pointing  to  exudation  in  the  membranes  of  the  brain  and  upon  the 
linings  of  its  ventricles. 

The  product  of  this  crasis  is  a  tubercle  presenting  many  peculiarities. 
It  is  a  scattered  corpuscle,  mostly  smaller  than  a  millet-grain,  and  no 
bigger  than  a  poppy-seed,  or  even  a  pin's  point.  It  is  now  of  glassy 
transparency,  vesicle-like ;  now  grayish,  semi-opaque,  soft,  gluey ; — 
then,  again,  verging  upon  whitish,  or  yellowish-white,  and  opaque. 
With  it  there  always  exudes  a  grayish,  more  or  less  albumen-sated,  semi- 
gelatinous  serosity,  infiltrating — drenching — the  involved  textures.  The 
deposition  of  these  products  always  affects  an  organ  in  wide  extension. 


298  CANCER-DYSCRASIS. 

Generally  speaking,  indeed,  several  organs  are  implicated  at  once,  more 
especially  the  lungs,  the  cerebral  pia  mater,  the  spleen,  the  liver,  and 
the  serous  membranes.  The  tubercle  is  always  deposited  in  great  num- 
bers, and  is  equably  disseminated  throughout  an  organ,  as  the  examina- 
tion of  an  involved  lung  or  spleen  shows  at  a  glance. 

The  tubercle  is  sometimes  primitive,  but  more  commonly  successive 
to  a  pre-existent  fibrin-tuberculosis.  Looking  at  the  physical  properties 
of  this  tubercle,  apart  from  any  chemical  analysis,  and  connecting  it 
with  the  crasis  of  which  it  is  the  product,  we  are  constrained  to  set  it 
down  as  an  albuminous  formation. 

With  reference  to  the  crasis  itself,  which,  as  we  have  said,  is  marked 
by  a  hypinosis  closely  resembling  the  exanthematous,  it  may  be  asked 
[and  the  question  is  replete  with  interest] :  is  acute  tuberculosis  primi- 
tive, or  is  it  but  a  consecutive  state  of  defibrination  of  the  blood,  brought 
about  through  the  antecedent  out-throwing  of  a  large  proportion  of  fibrin, 
in  the  shape  of  tubercle  ? 

Or  is  it  one  of  the  so  common  tuberculoses  connected  with  hydro- 
cephalic  effusion  of  the  internal  membranes  of  the  brain,  that  is,  con- 
secutive hypinosis,  determined  by  disease  of  the  brain  ? 

Seeing  that  acute  tuberculosis  occurs  under  conditions  which  preclude 
either  of  the  contingencies  here  referred  to,  not  a  doubt  can  remain  as 
to  its  protopathic  character. 

A  further  question  is :  how,  in  this  hypinotic  crasis,  is  the  tubercle 
brought  about  ? 

[For  a  reply  to  this  question  the  reader  is,  to  avoid  entire  repetition, 
referred  to  the  section  on  "  Albuminous  Tubercle,"  in  the  present 
volume,  p.  246.] 

Acute  tuberculosis  probably  always  proves  fatal. 

Occasionally,  owing  to  very  extensive  deposition,  the  crasis  approxi- 
mates to  hydrsemia.  It  does  not  pass  into  putrid  decomposition,  nor  is 
it  converted  into  pyaemia.  On  the  other  hand,  acute  softening  of  the 
stomach  is  a  frequent  follower  in  its  train. 

The  corpses  present,  generally  speaking,  the  same  phenomena  as  in 
typhus;  namely,  pale  skin,  extensive,  deep-colored  patches  of  lividity, 
tense,  dark-colored  muscles,  hypostatic  hypersemise.  The  parenchymata, 
especially  those  which  have  been  the  seat  of  tubercle-deposition,  are  tur- 
gescent,  and  drenched  with  sero-albuminous  fluid. 

(g.)   CANCER-DYSCRASIS. 

A  crasis  the  existence  of  which  is  shown  from  the  exclusive  relation 
stated,  in  the  general  section  on  Tubercle,  to  exist  between  cancer  and 
tuberculosis. 

To  demonstrate  a  cancer-dyscrasis  from  anatomico-clinical  data  is 
one  of  the  most  difficult  tasks.  The  basis  of  such  a  demonstration  is 
the  immediate  character  of  the  blood,  the  peculiarity  of  the  cancer- 
formation,  and  of  other  exudates  brought  about  in  various  ways  under 
the  crasial  influence  ;  and,  lastly,  their  relation  to  new  growths  proper 
to  other  known  erases. 

The  blood  itself  affords  evidence  of  a  hypinosis.     This  is,  however, 


CANCER-DYSCRASIS.  299 

not  of  itself  alone  cognizable  as  a  specific  cancer  hypinosis.  To  prove 
this  the  presence  of  cancer-formations  is  indispensable,  and  even  these 
must  needs  give  evidence  of  their  general  import,  either  by  redundant 
growth  or  by  multiplication  ;  in  short,  they  must  in  some  way  betoken  a 
direct  relation  with  a  dyscrasial  state  of  the  blood. 

Further  evidence  respecting  albuminosis  is  afforded  by  the  presence 
of  albuminuria,  of  lardaceous  infiltration  of  the  liver,  spleen,  kidneys ; 
more  particularly,  however,  by  inflammatory  products,  as  albuminous, 
white,  emulsion-like,  in  part  slowly  solidifying,  ulcerating,  or  cancer- 
forming  exudates  ;  lastly,  by  the  exclusion  of  concurrent  fibrinous  pro- 
ducts, and  especially  of  fibrinous  tubercle. 

The  abundant  fat-formation  not  unfrequently  co-existent  with  carci- 
noma may  be  cited  in  proof  of  the  participation  of  fat  in  the  cancerous 
albumen-crasis.  This  is  exemplified  in  osteo-porosis  from  the  excessive 
formation  of  bone-medulla  ;  in  the  fatty  contents  of  the  cancers,  and  of 
albumino-cancerous  exudates  ;  in  the  deposition  of  fat  as  cholesteatoma, 
as  gall-stone,  &c. 

The  cancerous  hypinosis  manifests  its  impress  in  various  grades.  It  is 
intense  in  cases  of  voluminous,  exuberant  cancers  ;  in  very  widely-spread 
cancer-production,  whether  spontaneous,  or  called  forth  by  the  extirpa- 
tion of  bulky  carcinomata ;  but  most  especially  in  cancer  of  acute  growth, 
and  of  the  medullary  character.  The  blood  often  contains,  in  nucleus- 
and  cell-formations,  the  elements  of  cancer.  In  chronic  vegetation, 
and  especially  in  pure  fibrin-cancer,  the  hypinosis  is  often  less  marked  ; 
whilst,  in  cancer  of  local  import,  it  may  be  altogether  wanting. 

The  cancer-crasis  is  either  primitive  or  consecutive,  that  is,  deve- 
loped out  of  a  hitherto  local  cancer.  It  is  either  acute  or  [more  often] 
chronic. 

The  acute  crasis  is  in  rare  instances  pvotopathic ;  more  commonly, 
however,  it  is  developed  out  of  the  chronic,  especially  after  the  extirpa- 
tion of  extensive  cancers.  It  localizes  now  in  the  more  vigorous  growth 
of  a  cancer  already  in  existence,  now  in  the  simultaneous  or  in  the  suc- 
cessive, hasty  production  of  new  cancers  [of  the  medullary  form]  in  the 
most  various  organs  and  textures,  conducing  thus  to  rapid  wasting  of 
the  blood,  and  proving  fatal  within  a  term  not  exceeding  that  of  the 
most  acute  erases  known. 

In  its  chronic  development  it  terminates  in  marasm  of  the  blood,  in 
hydrsemia,  in  anaemia,  the  more  rapidly,  in  proportion  as  the  seat  of  the 
cancer  [in  the  stomach,  for  example]  is  calculated  to  interfere  with 
the  work  of  nutrition,  or  in  proportion  to  the  loss  of  blood  by  hemor- 
rhage. 

Under  such  conditions  the  cancer-crasis  may  wear  itself  out,  and  the 
cancer-tumors  participate  in  the  waste  and  decline  of  the  entire  or- 
ganism. This  explains  the  circumstance  that  in  a  venosity  verging  upon 
hydrremia  and  depending  upon  central  organic  impediments  to  the  circu- 
lation, cancers  hardly  ever  occur. 

The  cancerous  hypinosis  is,  as  we  have  already  pointed  out,  absent  in 
local  carcinoma.  The  concurrent  crasis  may  be  the  normal,  or  some 
anomalous  one  not  of  a  cancerous  nature. 

The  fibrin-erases,  however,  accompanying,  or  at  least  coincident  with 


800  CANCER-DYSCRASIS. 

cancer,  are  of  great  interest,  not  alone,  as  running  counter  to  our  theory 
of  the  nature  of  cancer,  but  more  particularly  because,  if  correctly  seen 
and  comprehended,  they  afford  the  best  means  of  demonstrating  the 
specific  character  of  the  cancer-crasis. 

1.  In  the  first  place,  it  is  conceivable  that  fibrin-erases  may  become 
developed  along  with  local  cancer.     They  are,  no  doubt,  sometimes  pri- 
mitive, localizing  themselves  in  the  local  cancers,  as  inflammations  ; 
sometimes  consecutive,  that  is,  brought  about  in  the  cancer  itself  by 
mechanical  or  medicamental  influences.     The  fibrin-crasis  concurrent 
with  local  cancer  may  even  be  of  a  tuberculous  character,  and  lead  to 
tuberculous  deposition. 

2.  A  fibrin-crasis  may,  however,  become  developed  even  conjointly 
with  cancer  of  general  import,  that  is,  out  of  cancerous  hypinosis  or 
albuminosis.     The  cancer-crasis  is  co-ordinate  with  other,  similar  [hypi- 
notic]  erases,  out  of  which  we  have  seen  that  fibrin-erases,  more  espe- 
cially those  of  a  croupous  character,  may  emerge.     They  may  arise 
either  directly  out  of  the  hypinosis,  as  a  conversion  of  the  latter,  or  else 
through  the  instrumentality  of  an  inflammation  with  cancero-dyscrasial 
blood,  in  which  a  development  of  fibrin  takes  place. 

The  cancerous  fibrinosis,  in  whichever  way  brought  about,  localizes 
itself  in  inflammations  of  the  serous  tunics,  in  carcinomato-fibrinous 
hepatizations  of  the  lung,  as  also  in  spontaneous  coagulations  within  the 
vascular  system,  including  the  capillaries  [cancero-capillary  phlebitis]. 
Both  these  and  the  exudates  are  distinguished  for  their  opacity,  their 
whiteness  [changed  by  contained  blood-globules  to  grayish-red  or  red], 
their  soft,  lax  consistency,  their  albuminous  contents,  their  medullary 
characters.  They  are  sometimes  fundamental  to  cancer-formation, — 
the  most  acute  and  most  extensive  cancer-formation, — both  intra vascular 
and  extravascular.  At  other  times  they  liquefy  to  a  white,  cream-like, 
lardo-glutinous  ichor.  They  contain  the  rudimental  elements  of  cancer 
in  redundant  quantity. 

In  the  description  just  given,  a  peculiar  constitution  of  the  fibrin  under 
the  conditions  both  of  its  organizability  and  of  its  liquefying  tendency  is 
undeniable.  It  is  essentially  proper  to  cancer,  and  affords  incontestable 
proof  of  the  specific  constitution  of  the  albumen  in  cancerous  hypinosis. 
Where  a  fibrin  crasis  developes  itself,  whether  in  the  totality  of  the  blood 
or  in  a  local  process  [inflammation],  this  peculiarity  of  constitution  is, 
without  doubt,  transferred  from  the  albumen  to  the  fibrin.  A  proof, 
this,  how  intimately  it  clings  to  both  substances ;  a  proof  of  the  exist- 
ence of  a  cancerous  fibrin-crasis  ;  and  at  the  same  time  an  indication  of 
the  sense  in  which  the  balance  between  cancer-crasis  and  fibrin-crasis  is 
to  be  understood. 

This  cancerous  fibrinosis,  in  fine,  is  the  parent  of  a  peculiar  tubercle, 
of  cancero-fibrinous  character,  which  corresponds  well  with  cancer-crasis, 
and  more  particularly  with  such  of  its  highest  grades  as  have  attained 
the  point  of  fibrinosis ;  a  tubercle,  moreover,  which,  as  we  have  seen  at 
page  237,  answers  in  all  respects  to  cancerous  fibrin. 


ANEMIA.  301 


3.  HYDILEMIA;  ANEMIA. 
(a.)  The  Serous  Crasis ;  Hydrcemia. 

Fibrin,  albumen,  blood-globules,  are  here  all  diminished  in  quantity ; 
the  amount  of  water  increased.  The  blood  is  attenuate,  watery,  pale  in 
various  degrees  to  the  point  of  water  in  which  flesh  has  been  steeped, 
wanting  in  tenacity.  It  contains  very  inconsiderable,  loose,  soft,  curd- 
like  coagula  holding  much  serum,  which,  by  pressure  is  reducible  to  a 
few  drops. 

The  water  transudes  through  the  parietes  of  the  vessels  in  dependent 
parts,  or  in  such  as,  owing  to  mechanical  influences,  are  particularly  ob- 
noxious to  hyperaemia,  drenches  the  textures  in  the  form  of  oedema, 
especially  the  areolar  tissue,  even  to  the  medullary  system  of  the  bones, 
and  forms,  in  serous  cavities,  dropsical  effusion.  It  may  transude  pure, 
or  may  contain  a  certain  proportion  of  albumen  and  even  of  fibrin,  which 
latter  [as  so  called  spurious  fibrin]  determines  in  the  textures  a  soft  curd- 
like  coagulation  of  the  dropsical  fluid ;  and  in  the  cavities  separates  in 
the  shape  of  soft  curd-like  flakes.  Inflammatory  products  are  marked 
by  the  large  amount  of  their  serous  contents,  and  by  their  poverty  in 
plastic  materials. 

The  dropsical  crasis  occasions  defective  nutrition,  with  pallor  of  the 
textures,  relaxation  of  the  contractile  fibre ;  in  the  dead  body,  the  deve- 
lopment of  pale  death-patches. 

It  becomes  mortal  through  insufficiency  of  nutritive  matter  in  the  blood ; 
but  for  the  most  part  proves  fatal  at  an  earlier  stage  through  local  oedema 
of  the  textures,  and  dropsy  of  the  great  serous  cavities. 

Not  every  dropsy  is,  however,  the  result  of  hydraemia.  We  allude  to 
those  local  and  general  dropsies  brought  about  by  mechanical  impedi- 
ments to  the  circulation  in  the  veins,  in  the  heart  and  great  vascular 
trunks,  and  in  the  lungs. 

The  serous  crasis  is  sometimes  idiopathic,  produced  by  climatic  rela- 
tions, by  peculiar  alimentation,  by  anomalies  in  the  chylopoietic  system, 
by  repeated,  exhausting  hemorrhages,  &c.  Nay,  it  may  be  even  conge- 
nital and  constitutional.  The  condition  of  the  blood  in  hsemorrhophilis, 
seems  to  be  essentially  that  of  hydraamia.  In  most  instances,  however, 
it  is  secondary,  developed  as  a  sequela  to  some  other  crasis,  for  example, 
as  a  consequence  of  the  habitual  outpouring  of  albumen,  the  separation 
of  fibrin  in  large  aneurisms,  the  deposition  of  fibrin  and  albumen  in  in- 
flammation-products, in  tubercle,  in  cancer,  in  albuminuria.  Or  else  it 
ensues  upon  a  specific,  chronic  or  acute  blood-consuming  dyscrasis,  upon 
metallic  poisoning,  typhus,  and  the  like. 

(b.)  Ance?7iia. 

Deficiency  of  blood,  in  various  degrees,  by  no  means  offers  any  dis- 
tinctive crasial  characters,  if  we  except  the  hydraemia — the  excess  of 
water — into  which  every  persistent  ansemia  eventually  resolves  itself. 
The  anaemia  or  oligaemia,  is  brought  about  in  various  ways ;  for,  what- 


302  SEPTIC    CRASIS. 

ever  be  the  crasial  constitution  of  the  blood,  it  is  liable  to  an  accidental 
reduction  of  its  mass. 

It  is,  most  frequently  of  all,  a  consequence  of  loss  of  blood  through  the 
various  kinds  of  hemorrhage  ;  next  to  that,  of  insufficient  alimentation, 
of  excessive  bodily  and  mental  labor,  and  of  the  continuous  loss  of  fluids ; 
of  the  inordinate  production  and  increase  of  new  growths,  even  of  redun- 
dant fat  formation,  especially  in  children  ;  of  disease  of  the  nerve-cen- 
tres, especially  of  the  brain,  such  as  hypertrophy,  heterologous  growths, 
concussion.  Or  it  is  the  sequel  and  issue  of  intense  typhus-crasis  ;  of 
chronic  metallic  poisoning,  &c.  It  accompanies  all  general  atrophy, 
both  in  old  age  and  in  earlier  life. 

Moreover,  oligsemia  is  not  unfrequently  a  congenital,  constitutional 
state,  and  affects  by  preference  the  female  sex.  It  involves  a  correspond- 
ing defective  development  of  the  calibre  of  the  arteries,  with  smallness 
of  the  heart,  and  with  a  generally  stunted  growth  of  the  animal  frame. 
The  female  sexual  organs  seem  more  especially  crippled  in  their  develop- 
ment. It  was  stated  that  blood  of  every  admixture  may  suffer  an  acci- 
dental reduction  of  its  mass  through  hemorrhage,  without  becoming 
alienated  from  its  original  crasis.  In  like  manner,  anaemia  is  probably 
never  purely  such ;  that  is  to  say,  never  brought  about  by  the  equable 
reduction  of  each  of  its  constituent  parts,  but  at  the  same  time  invariably 
a  dyscrasial  condition.  How  inextinguishably  the  dyscrasis  clings  to 
croup  ous  blood,  even  after  the  most  copious  bloodlettings  ;  how,  in  the 
highest  grades  of  blood-deficiency,  the* tuberculous  constitution  attaches 
to  the  smallest  remnant  of  fibrin,  we  have  already  seen. 

The  most  striking  picture  of  anaemia  is  furnished  in  the  dead  bodies 
of  persons  who  have  died  of  hemorrhage.  Collapse  and  pallor  are  the 
outward  signs  reflected  from  within.  The  deathmarks,  if  there  be  any, 
are  very  pale.  There  is  considerable  rigidity  of  muscle,  firmly  contracted 
heart,  presenting  the  aspect  of  concentrical  hypertrophy,  bloodlessness, 
both  of  the  endocardial  cavities  and  of  the  vascular  trunks,  especially  the 
arteries.  In  corpulent  individuals  with  a  white  skin,  the  common  integu- 
ment is  of  a  waxy  paleness.  In  profound  dyscrasial  angemise  [the  con- 
sequence of  typhous  or  metallic  poison]  the  dead  subject  retains,  together 
with  the  pallor,  the  characteristic  cachectic  hue. 


4.   DECOMPOSITION.       PUTRID,    SEPTIC   CRASIS.       SEPSIS   OF    THE   BLOOD. 

We  have  repeatedly  had  to  refer  to  a  decomposition,  a  putrid  decom- 
position [sepsis]  of  the  blood,  as  a  consecutive  crasis  resulting  from  the 
degeneration  of  another  crasis. 

The  conditions  we  are  here  concerned  with  vary,  as  the  anatomical 
results  show,  with  the  causal  influences  at  work,  as  also  with  the  differ- 
ences due  to  pre-existent  erases. 

Generally  speaking,  these  conditions  manifest  themselves  in  decompo- 
sition, in  dissolution,  in  necrosis,  in  a  death  of  the  blood,  and  they  com- 
prise the  commonly  called  scorbutic,  the  chronic  and  acute,  putrid  states 
of  the  circulating  fluid.  A  very  broad  line  of  demarcation,  coming  under 
anatomical  notice,  and  which  separates  the  states  referred  to  into  tivo 


SEPTIC    CRASIS.  303 

series  is  that,  in  the  one  case,  the  sepsis  has  the  character  of  a  fibrin-cra- 
siSj  in  the  other,  that  of  a  deficiency  of  fibrin.  Accordingly,  if  we  except 
the  two  common  features  of  thinness  and  discoloration  of  the  blood  gene- 
rally, a  comprehensive  view  of  all  these  states  is  not  feasible. 

Regarded  from  a  clinico-anatomical  point  of  view,  the  various  condi- 
tions of  septic  crasis  occur  in  the  following  forms : 

1.  The  purest  and  most  simple  forms  of  sepsis  are  : 

(a.)  A  decomposition  or  necrosis  of  the  blood  brought  about  without 
any  cognizable  agent  of  fermentation  is  that  due  to  a  shattered  state  of 
the  nervous  system  and  of  its  function,  proving  fatal  with  lesser  or  greater 
rapidity  [sometimes  in  a  very  few  moments],  according  to  the  measure 
and  amount  of  the  shock.  To  this  category  are  to  be  referred  decompo- 
sitions of  the  blood  consequent  upon  concussion  and  severe  injuries,  con- 
cussion from  a  fall,  from  the  extensive  laceration  or  the  crushing  of  soft 
parts  or  of  bones ;  upon  extensive  amputations  ;  upon  the  continuous,  ex- 
hausting activity  of  the  muscles  in  violent  convulsions,  of  whatever  kind  ; 
upon  electrical  shocks  received  [lightning]  ;  upon  mental  emotion  of  an 
overwhelming  nature.  A  very  striking  exemplification  offers  in  the  de- 
composition of  the  blood  not  unfrequently  called  forth  by  a  difficult  and 
exhausting  act  of  parturition  involving  palsy  of  the  womb ;  cases  which 
often  prove  fatal  after  a  very  few  days,  or  even  hours. 

In  all  these  cases  the  blood  is  found  attenuate,  in  color  comparable  to 
a  raspberry  jelly,  or  of  a  dingy  red,  facile  of  imbibition,  expanded  in 
volume,  often  engaged  in  gas-development,  frothy.  The  blood-corpuscles 
are  swollen  up,  the  serum  being  deeply  reddened  by  hsematin  withdrawn 
from  them.  Coagula,  if  present  at  all,  appear  as  very  inconsiderable, 
soft,  curd-like  fibrin-clots.  The  frequent  large  peritoneal  exudates,  oc- 
curring more  especially  in  puerperal  decomposition,  are  dingy-red,  dull, 
thin,  sometimes  rather  viscid  fluids.  The  dead  bodies  present  but  little 
and  evanescent  rigor,  much  inflation,  extensive  and  deep  lividity.  The 
internal  organs,  the  heart's  muscle,  the  parenchymata  are  lax,  flabby ; 
the  bloodvessel  coats  and  the  endocardium,  discolored  from  imbibition ; 
those  parenchymata  whose  bloodvessels  are  most  injected  are  more  or 
less  discolored  by  imbibed  serum.  The  blood  is  always  largely  accumu- 
lated in  particular  sections  of  the  vascular  system,  be  it  in  the  nerve- 
centres,  in  extensive  patches  of  the  mucous  membrane  of  the  stomach 
and  intestines,  in  the  sexual  organs  of  women,  but  most  particularly  in 
the  lungs,  as  hypostasis. 

The  corpses  pass  into  putridity,  under  the  phenomena  of  gas-develop- 
nient  in  the  bloodvessels,  emphysema  in  the  textures,  copious  transuda- 
tion  of  a  dirty-red  serum  into  the  serous  cavities,  and  spontaneous  vesi- 
cation  of  the  epidermis. 

(b.)  Those  decompositions  consequent  upon  faulty  diet  [true  scurvy], 
the  reception  of  corrupt  matter,  of  miasmata,  of  animal  poisons  into  the 
blood,  &c. 

The  dead  bodies  present,  generally,  the  characters  already  specified. 
Owing,  however,  to  the  expansion  of  the  decomposed  blood,  transuda- 
tions  of  blood-dyed  serum  in  the  shape  of  ecchymoses  of  the  textures, 
and  actual  hemorrhages,  are  especially  apt  to  take  place. 

2.  A.  second  form  of  decomposition  is  that  so  frequently  attendant 


304  SEPTIC    CRASIS. 

upon  hypinotic  crasis,  and  which  we  have  before  described  as  an  exalta- 
tion or  degeneration  of  the  typhous,  of  the  exanthematous,  of  the 
cholera-,  of  the  drunkard's  dyscrasis.  Its  relation  to  the  fundamental 
crasis  may  be  regarded  as  a  varying  one.  Here  we  may  observe : 

(a.)  The  putrid  decomposition,  impelled  by  a  special  external  agent, 
becomes  complicated  with  the  hypinotic  crasis,  a  septic  venom  being 
superadded  to  the  exanthematous  contagion  or  the  typhous  miasma. 
There  being  essential  putrid  decompositions  independent  of  those  other 
agents,  and  the  symptoms  of  septic  poisoning  often  occurring  very  early 
during  the  progress  of  the  other  diseases  cited,  such  a  relation  is  placed 
beyond  all  doubt. 

(b.)  The  sepsis  is  a  dissolution  of  the  blood  in  the  hypinotic  crasis, 
resulting  from  the  profound  injury  inflicted  by  this  crasis  upon  the 
nervous  system.  This  implies,  either  a  very  intense  hypinosis  [a  very 
intense  miasma  or  contagion],  or  else  a  very  susceptible  nervous  system. 
Thus  it  may  happen  that  typhus  and  exanthemata  pass  into  putrid  de- 
composition even  in  epidemics  by  no  means  of  a  malignant  type. 

(c.)  Or,  in  fine,  it  is  possible  that  a  hypinosis  occasioned  by  miasma  or 
contagion,  may,  of  itself  and  without  the  mediation  of  the  nervous  system, 
become  degraded  into  a  putrid  crasis,  simply  through  putrid  conversion 
of  the  received  miasma.  It  is  in  this  sense,  more  particularly,  that  the 
exaltation  or  the  degeneration  of  a  primitive  crasis  to  the  putrid  is  to  be 
understood.  The  blood  and  the  corpse  present  the  same  appearances  as 
in  the  first  form ;  the  marks  of  decomposition  and  putrefaction  being, 
however,  if  possible,  still  more  clearly  defined.  The  different  hypersemiaa 
are  also  more  distinctly  expressed — such  hyperaemige  as  are  proper  to 
the  original  hypinoses.  They  occupy,  frequently  in  the  shape  of  ecchy- 
moses  and  hemorrhage  of  the  textures  into  which  they  have  degenerated, 
those  organs  or  parts  of  organs  in  which  the  original  hypinosis  had 
localized  itself ;  for  example,  the  intestinal  mucous  membrane,  in  putrid 
typhus ;  the  common  integument  and  the  great  tract  of  the  respiratory 
and  intestinal  mucous  membranes,  in  exanthematous  processes.  Not 
unfrequently,  the  septic  crasis  of  this  form  localizes  itself  in  deep-colored, 
absolute  stases,  especially  in  peripherous  organs,  where,  without  a  trace 
of  organizable  products,  they  terminate  in  necrosis  of  the  blood  and  of 
the  textures,  with  conversion  thereof  to  a  soft,  humid,  dingy,  deep-red 
mass, — a  gangrene-slough. 

A  stringent  differential  diagnosis  from  the  blood  itself  is,  however,  not 
feasible  in  all  the  cases  of  the  first  and  second  forms.  It  is  only  to  be 
deduced  from  the  anatomical  disturbance  of  the  solids  generally,  and,  in 
cases  of  the  second  form,  in  particular,  from  the  products  of  the  original 
hypinosis, — typhus,  exanthema,  &c.  For  instance,  where  the  intestinal 
mucous  membrane  reveals  the  marks  and  residua  of  a  typhous  process, 
the  sepsis  will  have  arisen  out  of  the  typhus-crasis.  Where  obvious 
anatomical  disturbance  does  not  exist, — for  example,  in  the  case  of  con- 
vulsions,— or  where  the  products  of  a  hypinosis,  owing  to  the  early 
supervention  of  sepsis,  are  inconsiderable  or  only  faintly  indicated,  and 
where,  lastly,  clinical  records  are  wanting,  the  diagnosis  must  needs  rest 
upon  probabilities  alone. 

3.  A  third  form,  differing  from  the  two  former,  is  that  of  a  sepsis  of 


ANOMALOUS    BLOOD-CORPUSCLES.  305 

the  blood  resulting  from  the  fibrin-crasis,  especially  the  aphthous,  and 
from  pyaemia.  It  manifests  itself,  in  the  first  instance,  as  a  putrid  decom- 
position, as  a  necrosis  of  the  fibrin,  which  forthwith  possesses  itself  of 
the  entire  blood-mass.  It  has  been  already  discussed  under  croupous 
crasis  /",  and  under  pyaemia,  as  aphthous  and  purulent  sepsis. 


INDEPENDENT  ANOMALIES   OF   THE   BLOOD-CORPUSCLES. 

An  anomalous  relation  of  the  blood-corpuscles,  founded  in  dyscrasial 
conditions  of  the  plasma,  occurs  under  several  forms,  some  of  which  have 
been  already  adverted  to,  especially  those  of  turgescence,  pallor,  or  pre- 
ternaturally  deep  coloration  ;  of  augmented  or  diminished  adhesiveness; 
and  the  like.  As  an  independent  anomaly,  their  diminished  number  in 
genuine  chlorosis  is  alone  recognized. 

Other  erases  deserving  of  notice  are  : 

The  hemorrhagic  crasis  [haemorrophilis],  specified  in  the  chapter  on 
"  Hemorrhage." 

A  crasis  tvhich  determines  the  deposition  or  stratiform  coagulation  of 
a  protein  substance  upon  the  inner  coat  of  bloodvessels  cannot,  in  our 
opinion,  be  pretermitted.  The  little  that  we  have  to  advance  upon  this 
subject,  however,  we  shall  reserve  for  the  chapter  on  "  Diseases  of  the 
Artaries,"  in  vol.  iii. 

The  retention  of  urea  in  the  blood  occasions  and  sustains  a  hypinotic 
crasis ;  and  in  certain  cases,  as  in  acute  nephritis  and  acute  albuminuria, 
tends  to  induce  a  complete  decomposition  of  the  blood. 

A  biliary  dyscrasis  is  produced  in  two  different  ways :  first,  through 
diseases  of  the  liver  and  gall-ducts, — inflammation  of  the  liver,  obstruc- 
tion of  the  latter  through  retention  in  the  blood  of  the  elements  of  the 
bile  ;  and  secondly,  through  endosmosis  of  bile  (resorption)  into  the  blood- 
vessels. 

The  croupous-crasis  and  pyaemia  often  give  rise,  without  demonstrable 
liver  affection,  to  the  elements  of  the  bile  being  set  at  large  in  the 
blood. 

In  fine,  there  is  a  spontaneous  biliary  crasis  which,  running  a  very 
acute  course  under  the  most  intense  typhoid  symptoms,  and  under  colli- 
quation  of  the  parenchyma  of  the  liver,  proves  fatal  through  decomposi- 
tion of  the  blood.  So  intense  and  violent  is  the  conversion  to  bile  in  the 
blood,  that  even  in  the  portal  circulation,  previous  to  its  entrance  into 
the  liver,  the  blood  has  the  look  of  blood  impaired  by  artificial  contact 
with  bile.  It  is  a  dingy-brown  or  yellow-red,  tenacious,  ichorous-looking 
fluid  intermingled  with  whitish  fat-streaks  and  jelly-like  particles  of 
fibrin.  The  bile  secreted  in  the  liver  is  so  saturated,  and  at  the  same 
time  so  excessive  in  quantity,  as  to  utterly  dissolve  the  parenchyma  of 

VOL.  i.  20 


306  ANOMALOUS    BLOOD-CORPUSCLES. 

that  organ, — that  is,  the  hepatic  cells — determining  a  state  of  collapse 
and  softening,  which,  in  its  appropriate  place,  we  shall  treat  of  as  "  Acute 
Yellow  Atrophy  of  the  Liver." 

With  regard  to  the  constitution  of  the  blood  in  gout,  syphilis,  chronic 
skin  eruptions,  and  many  other  diseases,  although  in  each  a  particular 
anomaly  does  no  doubt  exist,  it  has  not  as  yet  been  given  to  morbid 
anatomy  to  substantiate  its  nature. 


END    OF    VC*L.    I. 


EOKITANSKY'S 
PATHOLOGICAL  ANATOMY. 

VOLUME  II. 


A   MANUAL 


PATHOLOGICAL  ANATOMY. 


BY 


CARL  ROKITANSKY,  M.D., 

CURATOR  OF  THE  IMPERIAL  PATHOLOGICAL  MUSEUM,  AXD  PROFESSOR  AT  THE 
UNIVERSITY  OF  VIENNA,  ETC. 


VOLUME    II. 


THE 


ABDOMINAL  VISCEEA. 


TRANSLATED   FROM   THE   GERMAN, 


EDWARD   SIEVEKING,  M.D., 

MEMBER  OF  THE  COLLEGES  OF  PHYSICIANS   OF  LONDON  AND  HAMBURGH, 
PHYSICIAN  TO   THE   NORTHERN  DISPENSABY,  ETC. 


PHILADELPHIA: 
BLANC  HARD    &    LEA. 

1855. 


C.    SHERMAN    &    SON,    PRINTERS, 
19  St.  James  Street. 


EDITOR'S  PREFACE. 


THE  principal  hospital  of  the  Austrian  capital,  the  largest  in  the 
world,  offers  very  extensive  opportunities  and  unusual  facilities  for 
the  cultivation  of  Pathological  Anatomy.  Exclusive  of  the  Lying-in 
Hospital  and  the  Lunatic  Asylum,  which  occupy  the  same  range  of 
buildings,  the  Kaiserlich-Koniglich-Allgemeine-Krankenhaus1  (Im- 
perial Eoyal  General  Hospital)  contains  104  wards,  capable  of 
receiving  2214  patients ;  1247  beds  being  destined  for  males,  and 
967  for  females.  We  find  that,  in  1838,2  the  number  of  patients 
treated  amounted  to  20,545 ;  of  these,  2678  died,  giving  a  mortality 
of  13*03  per  cent.,  or  one  death  in  7*6  cases.  As  I  am  not  provided 
with  tables  of  mortality  for  other  years,  I  am  unable  to  state  the 
annual  average  mortality  in  the  hospital ;  but  it  does  not  appear,  by 
a  comparison  with  the  mortuary  tables  of  the  Viennese  Foundling 
Hospital,  that  the  year  1838  was  marked  by  peculiar  endemic  or 
epidemic  influences.  By  the  laws  of  the  hospital,  post-mortem 
examinations  may  be  made  of  all  who  die  within  its  walls.4  "  To 
examine  all,  or  one  half,  would  be  impossible;"  but  as  "generally 
from  four  to  six  bodies  are  opened  daily,"5  the  extent  of  the  field 
presented  for  cadaveric  research  may  easily  be  estimated.  For  a 
series  of  years,  the  Professorship  of  Pathological  Anatomy  has 
been  held  by  Dr.  CARL  ROKITANSKY,  and  the  numbers  of  medical 
men  of  all  nations  who  are  attracted  to  Vienna  by  him,  are  the  best 

1  Knolz,  Darstellung  der  Humanitats  und  Heilanstalten  Wiens,  &c.     Wien,  1840,  p.  169. 
Wilde,  Austria  and  its  Institutions.     Dublin,  1843,  p.  124. 

2  Knolz,  1.  c.  p.  316.  3  Ib.  1.  c.  p.  56. 

4  Ib.  1.  c.  p.  190.  5  Wilde,  1.  c.  p.  180. 


Vlll  PREFACE. 

evidence  of  the  manner  in  which  he  has  availed  himself  of  the 
opportunities  at  his  disposal.  All  who  have  heen  fortunate  enough 
to  attend  the  Professor's  demonstrations,  will  he  ahle  to  award  him 
the  praise  of  untiring  industry,  of  acute  judgment,  and  candid  re- 
search. Records  of  every  case,  taken  down  at  the  dictation  of  the 
Professor,  are  kept,  and  all  interesting  specimens  are  preserved  for 
the  Pathological  Museum.  Eokitansky  has  emhodied  the  facts 
ohserved,  and  the  conclusions  deduced  from  them,  in  his  "  Hand- 
buch  der  Pathologischen  Anatomie,"  published  in  Vienna  during 
the  years  1841-1846.  The  original  forms  three  large  octavo 
volumes ;  of  which  the  third,  containing  the  Pathological  Anatomy 
of  the  Organs  of  Respiration  and  Nutrition,  and  of  the  Uro-Genital 
Tract,  appeared  first ;  the  second,  embracing  the  Morbid  Anatomy 
of  the  remaining  Organs  and  Systems  of  the  Body,  followed ;  and 
the  first,  in  which  the  Professor  gives  a  philosophical  survey  of  the 
entire  Science  of  Morbid  Anatomy,  was  published  last.  The  Council 
of  the  Sydenham  Society  have  determined  upon  issuing  the  trans- 
lation in  a  similar  sequence.  Owing  to  the  acknowledged  difficulty 
of  the  author's  style,  it  has  however  been  thought  advisable  to 
divide  the  translation  into  four  volumes,  each  of  which  is  intrusted 
to  a  different  editor. 

The  present  volume  contains  the  morbid  anatomy  of  the 
Digestive  Apparatus  and  the  Uro-Genital  Viscera,  which  constitute 
the  greater  part  of  the  third  volume  of  the  original.  The  succeed- 
ing two  volumes  will  embrace  the  remaining  portion  of  the  third, 
and  the  second  volume  of  the  original,  and  each  of  these  will  be 
complete  in  themselves,  as  far  as  regards  the  Special  Pathology  of 
the  parts  of  which  they  treat.  The  first  volume,  which  contains  the 
Principles  or  Theory  of  Morbid  Anatomy,  is  a  scientific  expose  of 
the  deductions  and  inferences  drawn  by  the  author  from  the  facts 
and  illustrations  given  in  the  other  sections  of  the  work,  and  will 
be  the  last  to  appear.  His  views,  as  laid  down  in  the  volume  of 
General  Morbid  Anatomy,  are  unintelligible  to  one  who  has  not 
previously  studied  the  volumes  of  Special  Pathology ;  this  accounts 
for  the  apparent  inconsistency  of  publishing  the  translation  in  the 


PREFACE.  IX 

order  adopted.  "Were  it  not  that  the  Council  of  the  Society  have 
desired  to  adhere  as  much  as  could  conveniently  be  done  to  the 
original,  the  present  volume  might  with  perfect  propriety  have  been 
termed  the  first,  and  the  succeeding  volumes  have  been  numbered 
in  the  order  of  their  publication. 

The  fact  of  the  Work  having  been  selected  for  translation  by  the 
Council  of  the  Sydenham  Society,  is  in  itself  a  proof  that  it  is 
deserving  of  the  high  estimation  in  which  it  has  tbeen  held  by  all 
pathologists  acquainted  with  continental  literature ;  but  it  may  not 
be  superfluous  to  state  that  the  value  of  the  Professor's  remarks  is 
enhanced  by  his  being  entirely  unfettered  by  preconceived  notions 
or  prejudiced  views,  as  to  the  disease  of  the  individual  brought  to 
the  dead-house  for  examination.  "  Kokitansky,"  as  Mr.  Wilde 
correctly  remarks,  "  differs  from  all  other  pathologists,  in  not  en- 
gaging in  the  study  or  treatment  of  disease  during  life ;  he  is  not  a 
practical  physician,  and  seldom  sees  one  of  the  many  hundreds  of 
cases,  whose  bodies  he  dissects.".  English  readers  will  probably 
sometimes  desire  more  positive  statistical  data  than  the  author 
vouchsafes,  and  I  cannot  but  express  a  hope  that  in  the  new  edition 
which  Professor  Rokitansky  is  preparing,  he  will  in  some  measure 
repair  an  omission,  which  necessarily  weakens  his  conclusions,  and 
deprives  them  of  that  basis  which  the  student  looks  for  in  patho- 
logical anatomy,  more  even  than  in  other  departments  of  the  natural 
sciences.  I  may,  however,  venture  to  assert,  that  no  one  will  read 
his  descriptions  of  post-mortem  appearances  without  feeling  con- 
vinced that  they  are  drawings  from  nature. 

Of  the  difficulties  connected  with  the  translation,  I  will  only  say 
that  they  are  much  increased  by  the  figurative  style  of  the  author. 
He  constantly  uses  terms  in  a  sense  peculiar  to  himself,  and  his 
total  disregard  for  the  ordinary  rules  of  composition  is  an  additional 
and  frequent  source  of  obscurity.  It  has  been  necessary  to  adopt  a 
few  terms  in  the  translation  which,  though  new  to  the  reader,  have 
been  thought  to  convey  most  accurately  the  peculiar  and  idiomatic 
expressions  of  Professor  Kokitansky ;  this  has  not,  however,  been 


X  PREFACE. 

done  except  where  no  word  or  phrase  familiar  to  British  pathologists 
could  be  found  exactly  to  convey  the  meaning  of  the  author. 

In  regard  to  the  translation  generally,  I  can  only  express  a  hope 
that  I  have  not  perverted  the  sense  of  the  original  by  the  necessary 
reconstruction  of  many  passages,  nor  that,  in  adhering  too  closely 
to  the  German,  I  have  failed  in  making  the  English  edition  readable. 

In  conclusion,  I  avail  myself  of  this  opportunity  to  acknowledge 
the  honor  conferred  upon  me  by  the  request  of  the  Council  of  the 
Sydenham  Society  to  undertake  the  translation ;  and  I  have  great 
pleasure  in  recording  the  obligations  which  I  am  under  to  Dr.  J.  E. 
Bennett,  the  Secretary  of  the  Society,  for  the  courtesy  and  assist- 
ance he  has  afforded  me  while  the  work  was  going  through  the 
press. 

E.  S. 

BROOK  STREET,  GROSVEXOR  SQUARE. 


CONTENTS  OF  VOLUME  II. 


PART  I. 

ABNORMITIES   OF  THE   DIGESTIVE   APPARATUS. 

CHAPTER  I. 


PACE 


ABNORMITIES  OF  THE  ALIMENTARY  TUBE,             .            .            .            .  .17 

SECT.  I. — Abnormities  of  the  Mouth  and  Fauces,  .  .  .  .  17 

|  1.  Deviations  in  Form  and  Size,  ...  17 

$  2.  Textural  Diseases,  ....  18 

§  3.  Adventitious  Growths,  ....  20 

§  4.  Anomalies  in  the  Secretions,  .....  20 

SECT.  II. — Abnormities  of  the  Pharynx  and  (Esophagus,             .  20 

§  1.  Defect  and  Excess,              ......  20 

$  2.  Acquired  Abnormities  of  the  Calibre,  and  the  thickness  of  the  Parietes,         20 

g  3.  Anomalies  of  Position,         .             .             .             .             .             .  21 

$  4.  Solutions  of  Continuity,              .             .             .             .             .  .21 

$  5.  Textural  Diseases,  .......  22 

§  6.  Foreign  Bodies,  ....  93 

SECT.  III. — Abnormities  of  the  Peritoneum,  ....  23 

|  1.  Defect  and  Excess  of  Formation,  .  .  .  .  .23 

§  2.  Anomalies  in  the  Size  and  Form  of  the  Peritoneal  Sac,  .  .  24 

§  3.  Solutions  of  Continuity,  ...  24 

§  4.  Abnormities  of  the  Tissues,  ...  24 

§  5.  Morbid  Contents  of  the  Peritoneal  Cavity,  .  .  .  .30 

SECT.  IV. — Abnormities  of  the  Stomach,       ....  30 

$1.  Original  Arrest  of  Development,             ....  30 

§  2.  Deviations  of  Size,               .....  30 

§  3.  Deviations  of  Form,       .....  31 

§  4.  Deviations  of  Position,         .....  32 

$  5.  Solutions  of  Continuity,              ....  32 

g  6.  Diseases  of  the  Tissues,      .            .            .            .            .            .  32 

§  7.  Anomalous  Contents  of  the  Stomach,  ....  46 

SECT.  V. — Abnormities  of  the  Intestinal  Canal,         ....  47 

|  1.  Defective  and  Excessive  Formation,      ....  47 

$  2.  Abnormities  of  Size,            ......  48 

§  3.  Deviations  of  Position,  .             .             .             .             .             .  .         50 

§  4.  Solutions  of  Continuity,        .....  57 

§  5.  Diseases  of  the  Tissues,  ......         58 

§  6.  Anomalies  of  the  Intestinal  Contents,  .  92 


XU  CONTENTS. 

CHAPTER  II. 

PAGE 

ABNORMITIES  OF  THE  ACCESSORY  ORGANS  OF  THE  ALIMENTARY  CANAL,  .        97 

SECT.  I. — Abnormities  of  the  Liver,   .  .  .  .  .  .  97 

g  1.  Arrest  and  Excess  of  Development,      .  ...         97 

\  2.  On  the  Irregularities  of  Volume  generally,  and  on  Hypertrophy  and 

Atrophy  in  particular,  .  ....         97 

g  3.  Abnormities  of  Form,          .  .  .  .  .  .  101 

\  4.  Abnormities  of  Position,  .  .  .  .104 

\  5.  Changes  of  Consistency,      ...  105 

|  6.  Diseases  of  the  Tissues,      '  .  .  .  .  .105 

SECT.  II. — Abnormities  of  the  Biliary  Passages,         ....  123 

\  1.  Excess  and  Defect  of  Formation,  .....       123 

§  2.  Irregularities  of  the  Biliary  Passages  with  reference  to  Calibre,     .  124 

§  3.  Anomalies  in  the  Form  and  Disposition  of  the  Biliary  Passages,          .       126 
I  4.  Solutions  of  Continuity,       .  .  .  .  .  .  126 

|  5.  Textural  Diseases,         .......       126 

§  6.  Adventitious  Products,         .  .  .  .  .  .  127 

$  7.  Anomalous  Contents  of  the  Biliary  Passages,    ....       128 

SECT.  III. — Abnormal  Conditions  of  the  Spleen,       .  .  .  .  130 

\  1.  Defect  and  Excess  of  Formation,  .  .  .  .  .130 

\  2.  Deviations  of  Size,  ......  131 

\  3.  Deviations  of  Form,       .  .  .  .  .  .  .132 

|  4.  Deviations  of  Position,         .  k    .  .  .  .  132 

|  5.  Solutions  of  Continuity,  .  !  .  .  .  .133 

\  6.  Diseases  of  Texture,  .  .  .  .  .  .  133 

SECT.  IV. — Abnormities  of  the  Pancreas,  and  the  other  Salivary  Glands,  .       139 

\  1.  Abnormities  of  the  Pancreas  and  the  Salivary  Glands,       .  .  139 

$  2.  Abnormities  of  the  different  Ducts  and  of  their  Contents,         .  .       141 


PAKT   II. 

ABNORMITIES  OF  THE  URINARY  ORGANS. 

SECT.  I. — Abnormities  of  the  Kidneys,     ......       145 

$  1.  Defect  and  Excess  of  Formation,    .....  145 

\  2.  Deviations  of  Size,         .......       146 

g  3.  Deviations  of  Form,  ......  146 

$  4.  Deviations  of  Position,  .......       146 

§  5.  Deviations  of  Consistency,  ......  147 

\  6.  Solution  of  Continuity,  .  .  .  .  .  .  .147 

\  7.  Diseases  of  the  Tissues,      .  .  .  .  .  .  147 

$  8.  Special  Diseases  of  the  Investments  of  the  Kidneys,  .  .  .162 

SECT.  II. — Diseases  of  the  Urinary  Passages,  .  .  .  .  163 

§  1.  Defect  and  Excess  of  Formation,  .....       163 

\  2.  Deviations  of  Calibre,          .  .  .  .  .  .  164 

§  3.  Anomalies  of  Position,  .  .  .  .  .  .165 

g  4.  Anomalies  of  Texture,  .  .  .  .  .  .  165 

SECT.  III. — Abnormities  of  the  Urinary  Bladder,  .  .  .  .168 

\  1.  Defect  and  Excess  of  Formation,  .  .  .  .  .  168 

$2.  Deviations  of  Size  and  Form,  ......  169 


CONTEXTS.  XM1 

PAGE 

§  3.  Anomalies  of  Position,         .             .             .             .             .            .  171 

§  4.  Solutions  of  Continuity,  ......       171 

§  5.  Anomalies  of  Texture,         ......  172 

SECT.  IV.— Abnormities  of  the  Urethra,               .            .            .            .  .177 

|  1.  Defective  Development,       .            .            .            .            .            .  177 

I  2.  Deviations  of  Size,         .            .            .            .            .            .  .178 

g  3.  Deviations  of  Direction,       .            .            .            .             .             .  178 

\  4.  Solutions  of  Continuity,              .             .             .             .            .  .178 

\  5.  Diseases  of  the  Tissues,      ......  178 

§  6.  Anomalous  Contents  of  the  Urinary  Passages,              .            .  .       181 


PART    III. 

ABNORMITIES  OF  THE  SEXUAL  ORGANS. 

CHAPTER  I. 
Ox  ABNORMITIES  OF  THE  SEXUAL  ORGANS  GENERALLY,    ....      191 

CHAPTER  H. 

ABNORMITIES  OF  THE  MALE  ORGANS  OF  GENERATION,      .            .            .  .192 

SECT.  I.— The  Testes  and  Vasa  Deferentia,   .            .            .            .            .  192 

§  1.  Defect  and  Excess  of  Formation,          .....       192 

£  2.  Deviations  of  Size,              .            .            .            .            .            .  192 

§  3.  Deviations  of  Position,               .             .             .             .             .  .193 

§  4.  Diseases  of  the  Tissues,  .  .  .  .  .  .  193 

SECT.  II.  Abnormities  of  the  Vesiculae  Seminales,           .             .             .  .195 

$  1.  Arrest  and  Excess  of  Development,             .             .                          .  195 

§  2.  Deviations  of  Size,         .             .             .             .             .             .  .195 

\  3.  Diseases  of  the  Tissues,       .            .            .            .            .            .  195 

§  4.  Morbid  Growths,            .            .            .            .            .            .  .196 

$  5.  Anomalies  of  the  Contents  of  the  Vesiculae  Seminales,  .  .  196 

SECT.  III. — Abnormities  of  the  Prostate,              .             .             .             .  .197 

§  1.  Abnormities  of  Size,             .             .             .             .             .             .  197 

§  2.  Diseases  of  the  Tissues,  .  .  .  .  .  .197 

SECT.  IV. — Abnormities  of  the  Penis,             .....  197 

|  1.  Defect  and  Excess  of  Formation,          .            .            .            .  .198 

§  2.  Deviations  of  Size,  .            .            .            .            .            .            .  199 

\  3.  Diseases  of  the  Tissues,  .  .  .  .  .  .199 

SECT.  V. — Abnormities  of  the  Cutaneous  Covering  of  the  Penis  and  Scrotum,  200 

§  1.  Defect  and  Excess  of  Formation,          .            .            .            .  .200 

§  2.  Anomalies  of  Size,               ......  200 

\  3.  Diseases  of  the  Tissues,  .  .  .  .  .  .200 

CHAPTER  III. 

ABNORMITIES  OF  THE  FEMALE  SEXUAL  ORGANS,         .            .            .            .  201 

The  External  Genitals. 

SECT.  I— Abnormities  of  the  Pudenda,     .            .            .            .            .  .201 


XIV  CONTENTS. 

PAGE 

SECT.  II. — Abnormities  of  the  Vagina,           .            .             .             .             .  201 

I  1.  Defect  and  Excess  of  Formation,          .             .             .             .  .201 

\  2.  Anomalies  of  Size,              ......  202 

|  3.  Deviations  in  Position  and  Form,  .....       203 

1 4.  Solutions  of  Continuity,       .             .             .             .             .             .  203 

I  5.  Diseases  of  the  Tissues,             .            .            .            .            .  .204 

§  6.  Anomalies  of  the  Contents  of  the  Vagina,               .             .             .  206 

TJie  Internal  Sexual  Organs. 

SECT.  I. — Abnormities  of  the  Uterus,       ......       206 

3  1.  Defect  and  Excess  of  Formation,    .....  206 

I  2.  Anomalies  of  Size,         .  .  .  .  .  .  .212 

§  3.  Anomalies  of  Form,  .  .  .  .  .  .  214 

1 4.  Deviations  of  Position,  .  .  .  .  .  .  .215 

§  5.  Deviations  of  Consistency,  .  .  .  .  .  .  216 

I  6.  Solutions  of  Continuity,  .  .  .  .  .  .217 

§  7.  Diseases  of  the  Tissues,      .  .  .  .  .  .  217 

SECT.  II. — Diseases  of  the  Uterus  after  Parturition,         ....       229 

g  1.  On  Defective  and  Irregular  Contraction  and  Involution  of  the  Uterus 

after  Childbirth,  .  .  .  .  .  .  .229 

\  2.  Puerperal  Inflammations,    .  .  .  .  .  .  230 

SECT.  III.— Abnormities  of  the  Fallopian  Tubes,  .  .  .  .242 

§  1.  Defect,         ........  242 

§  2.  Anomalies  of  Calibre,    .  •  <  •  •  •  .242 

•   $  3.  Anomalies  of  Position  and  Direction,          ....  242 

\  4.  Diseases  of  the  Tissues,  ......      243 

SECT.  IV. — Abnormities  of  the  Ovaries,        .....  245 

$  1.  Defect  of  Formation,     .......       245 

I  2.  Deviations  of  Size,  .  .  .  .  .  .  245 

\  3.  Diseases  of  the  Tissues,  ......       245 

SECT.  V. — Abnormities  of  the  Mammary  Glands,      .  .  .  .  253 

§  1.  Arrest  and  Excess  of  Formation,  .....       253 

|  2.  Anomalies  of  Size,  .  .  .  .  .  .  253 

$  3.  Diseases  of  the  Tissues,  .  .  .  .  .  .254 

SECT.  VI. — Abnormities  of  the  Ovum,  .....  255 

$  1.  Extra-uterine  Pregnancy,  ......       256 

I  2.  Degeneration  of  the  Ovum,  .....  258 

§  3.  Abnormities  of  the  Separate  Parts  of  the  Ovum,          .  .  .      258 


PART   I. 

ABNORMITIES  OF  THE  DIGESTIVE  APPARATUS. 


CHAPTER  I. 

ABNORMITIES  OF  THE  ALIMENTAEY  TUBE. 


SECT.   I. — ABNORMITIES   OP   THE   MOUTH  AND   FAUCES. 

§  1.  Deviations  in  Form  and  Size. — As  excess  of  development,  we 
have  here  to  mention  the  more  or  less  complete  repetition  of  one  or  more 
parts,  which  sometimes  advances  to  such  an  extent  that  the  bones  of  the 
jaws,  the  mouth,  and  the  tongue  are  double,  and  unite  in  one  common 
gullet.  As  defective  formation,  which  may  generally  be  distinctly 
traced  to  an  arrest  of  development,  we  meet  with  complete  absence  of 
the  cavities  of  the  mouth  and  fauces  (astomia),  or  imperfect  development 
of  individual  parts,  as  of  the  superior  maxilla,  giving  rise  to  an  imper- 
fect development  of  the  face  (ateloprosopia),  of  the  lower  jaw  (agnfathia 
and  atelognathia),  of  the  lips  (achelia  and  atelochelia),  of  the  tongue,  &c. 

The  most  common  and  important  cases  of  arrest  of  development  are : 
Fissures  of  the  upper  lip,  on  either  or  both  sides  of  the  mesian  line, 
corresponding  to  the  union  of  the  intermaxillary  with  the  superior  max- 
illary bones,  which  may  or  may  not  present  a  fissure  also  (harelip, 
labium  leporinum) ;  fissures  of  the  palate,  caused  by  the  absence  of  the 
os  incisivum  and  the  middle  portion  of  the  upper  lip,  or  by  the  mere  dis- 
union of  the  palatal  processes  in  the  middle  line  ;  or  again,  by  defect  in 
the  latter  on  either  or  both  sides,  with  or  without  an  accompanying  ab- 
sence of  the  os  incisivum  ;  the  fissures  of  the  soft  palate,  varying  equally 
in  degree,  from  complete  division  to  a  mere  indication  of  the  anomaly  in 
a  slight  notch  of  the  uvula.  Fissures  of  the  tongue  are  extremely  rare, 
and  seldom  present  more  than  a  mere  trace  of  division ;  fissures  of  the 
nether  lip,  and  of  the  lower  jaw  in  the  mesian  line,  are  equally  rare. 

Closure  of  the  mouth  (atresia  oris)  is  a  rare  occurrence,  as  contrasted 
with  the  frequency  of  a  similar  condition  at  the  anus. 

Numerous  morbid  processes  are  followed  by  anomalies  that  resemble 
the  above  congenital  malformations,  such  as  partial  or  total  loss  of  the 
lips,  of  the  cheeks,  of  the  palate,  contraction  of  the  mouth  to  a  degree 
approaching  atresia,  adhesion  of  the  cheeks  to  the  maxillae,  of  the  tongue 
to  the  cavity  of  the  mouth,  contraction  of  the  fauces,  &c. 

Increase  of  size,  as  a  result  of  hypertrophy,  occurs  chiefly  in  the 
shape  of  hypertrophy  of  the  lips  and  the  tongue ;  it  varies  in  degree, 
and  is  peculiar  to  the  scrofulous  cachexia  and  to  cretinism ;  it  is  also 
presented  as  hypertrophy  of  the  tonsils,  and  of  the  glandular  stratum 
of  the  soft  palate,  as  hypertrophy  of  the  uvula,  and  occasionally  of  the 
gums. 

VOL.    II.  2 


18  ABNORMITIES    OF    THE 

The  opposite  condition,  i.  e.  diminution  of  size  and,  taken  in  reference 
to  the  capacity  of  the  oral  cavities  and  the  fauces,  contraction,  occurs  in 
an  eminent  degree  in  the  shape  of  atrophy  of  the  tonsils,  and  also  of  the 
other  muciparous  glands,  and  of  stenosis  of  the  isthmus  faucium.  The 
latter  results  from  cicatrization  of  syphilitic  and  scrofulous  ulcers,  and 
occasionally  proceeds  to  such  a  degree  that  the  isthmus  scarcely  permits 
the  passage  of  a  pea. 

§  2.  Textured  Diseases. — Of  these,  inflammatory  processes,  and  espe- 
cially those  affecting  the  mucous  membrane  and  its  glands,  demand 
primary  consideration. 

Catarrhal  inflammation  is  particularly  liable  to  attack  the  pharyngeal 
mucous  membrane,  and  to  be  associated  with  a  marked  affection  of  the 
tonsils,  in  the  shape  of  cynanche  tonsillaris.  It  is  either  acute,  or 
chronic,  is  apt  to  return,  and  become  .habitual;  it  frequently,  and  in 
many  individuals  constantly,  passes  not  only  into  superficial  ulceration, 
but  even  into  phlegmonous  inflammation  and  the  formation  of  abscesses 
in  the  tonsils ;  or  it  leaves  a  permanent  relaxation  of  the  fauces,  with  a 
varicose  state  of  the  vessels,  elongation  and  oedema  of  the  uvula,  chronic 
hyperaemia,  and  tumefaction  of  the  tonsils,  and  blennorrhoea  of  the 
tonsils  and  fauces.  It  frequently  extends  to  the  mucous  membrane  of 
the  rima  glottidis  and  of  the  larynx,  as  well  as  to  that  of  the  Eustachian 
tube.  * 

The  croupy  process  of  the  mucous  membrane  of  the  mouth  and  fauces 
occurs,  in  the  first  instance,  in  the  well-known  form  of  thrush  and 
aphthae  in  children  ;  and  in  adults,  commonly  with  an  epidemic  character 
of  an  adynamic  septic  type,  as  malignant  (gangrenous,  aphthous)  sore 
throat  (angina  gangrsenosa,  the  diphtheritis  of  Bretonneau).  In  the 
former  case,  after  a  previous  vivid  or  dark  purple  reddening  of  one  or 
more  papillae,  and  the  vesicular  elevation  of  the  epithelium  at  the  point 
and  the  sides  of  the  tongue,  dots  or  patches,  of  the  size  of  a  lentil  or 
pea,  appear  on  the  inner  surface  of  the  lips  and  cheeks,  and  finally,  on 
the  mucous  membrane  of  the  fauces.  They  present  an  exudation,  which 
has  a  frosted,  or  flocculent,  or  villous  appearance,  or  is  more  of  a  mem- 
branous character,  and  extends  into  the  cavities  of  the  follicles ;  it  is  of 
a  grayish,  or  yellowish-white  color,  and  of  a  lardaceous,  or  soft,  creamy, 
or  fluid  consistency ;  if  removed,  a  shallow  excoriated  depression,  sur- 
rounded by  an  inflamed  margin,  remains,  on  which  the  exudation  is 
repeated,  involving  a  further  destruction  of  the  mucous  tissue. 

In  the  second  instance,  livid  spots,  which  rapidly  coalesce,  and  become 
invested  with  a  dirty,  gray,  shaggy,  pultaceous  and  sanious  exudation, 
form  upon  the  softened,  bleeding  gums,  and  the  mucous  membrane  of  the 
cheeks,  the  fauces,  and  the  tonsils.  The  gums  themselves  ultimately 
degenerate  into  a  bad-looking,  pulpy,  sanious  mass,  and  the  mucous 
membrane  of  the  cheeks  and  fauces,  underneath  the  exudations,  is 
equally  found  converted  into  a  friable,  fetid  pulp,  or  a  firm  slough. 

These  processes  often  extend  to  the  pharynx  and  the  oesophagus, 
though  scarcely  ever  to  the  respiratory  passages ;  they  are  sometimes 


MOUTH    AND    FAUCES.  19 

complicated  with  exudative  processes  on  other  mucous  and  serous  mem- 
branes. 

Genuine  (primary)  pharyngeal  croup  occurs  rarely ;  it  is  either  the 
result  of  an  extension  of  tracheal  croup,  or,  similar  to  exudative  pro- 
cesses with  products  of  a  different  nature,  an  anomalous  process  of  a 
specific,  acute,  exanthematic,  impetiginous,  typhous  character,  or  it  is 
the  result  of  a  spontaneous  or  purulent  disorganization  of  the  blood.  It 
not  unfrequently  leads  to  acute  gastric  softening. 

Pustular  inflammation  occurs  in  the  fauces  in  variolous  disease ;  the 
mucous  membrane  being  tumefied,  and  invested  with  a  plastic  mucous 
secretion. 

There  are  other  circumscribed  inflammations  of  the  buccal  and  pha- 
ryngeal mucous  membranes,  which  are  remarkable  for  their  tendency  to 
pass  into  ulceration,  viz.  the  syphilitic,  syphiloid,  mercurial,  and  scrofu- 
lous inflammations.  They  are  generally  characterized  by  their  peculiar 
red  tinge  and  defined  edges,  and  give  rise  to  various  products  which  dis- 
solve the  tissues  in  a  peculiar  manner,  and  consequently  to  specific 
ulcers.  Syphilis,  more  particularly,  is,  in  this  phase  of  its  existence, 
and  so  far  as  the  alimentary  tract  is  concerned,  limited  to  the  fauces. 

The  last-mentioned  ulcers  and  aphthous  ulcerations,  give  rise  to  more 
or  less  considerable  loss  of  substance  in  the  mucous  membrane  and  the 
subjacent  tissues,  after  the  cure  of  which,  white,  indurated,  elevated  re- 
tiform,  and  tendinous  cicatrices  remain,  which  induce  a  corresponding 
contraction. 

Among  the  inflammations  attacking  individual  structures,  we  have  to 
mention  inflammation  of  the  gums,  especially  the  rheumatic  variety,  with 
coexisting  affection  of  the  alveolar  periosteum,  as  also  the  scorbutic 
forms  and  the  inflammation  of  the  tongue  with  its  occasional  termination 
in  deep-seated  suppuration. 

An  important  disease  that  we  must  here  speak  of,  is  noma,  a  phage- 
clenic  ulceration  which  commences  at  the  inner  surface  of  the  cheek,  and 
rapidly  spreads,  involving  the  soft  parts  in  gangrenous  destruction.  A 
livid  congestion  of  the  mucous  membrane  precedes,  corresponding  with 
which  there  is  an  erysipelatous  redness  externally  ;  a  hard  tumor  then 
forms ;  the  tissues  are  broken  up  into  a  pulpy  sanious  mass,  the  subcu- 
taneous cellular  tissue  is  dissolved  into  a  pale  yellowish,  gelatinous,  oily 
mass  ;  the  superficial  integument,  at  the  same  time,  becomes  pale,  and  is 
converted  into  a  similar  mass,  or  dries  up  into  a  dry,  brownish-black 
eschar ;  the  surrounding  parts  presenting  erysipelatous  redness  and 
oedema.  This  process  not  unfrequently  spreads  over  the  entire  cheek 
and  gums,  denuding  the  maxillary  bones,  and  involving  them  in  a  spe- 
cies of  calcination.  (Froriep.)  It  is  rarely  met  with  except  in  children, 
and  commonly  attacks  weakly  cachectic  individuals ;  it  frequently  occurs 
as  a  sequela  of  exanthematic  diseases,  and  of  typhus,  and  then  repre- 
sents a  degeneration  or  an  anomaly  in  the  latter. 

§  3.  Adventitious  Growths. — Among  these  we  have  first  to  notice  the 
fibroid  tumors  occurring  on  the  alveolar  processes  under  the  name  of 
epulis,  and  in  the  fauces  as  polypi ;  they  have  a  broad  base,  or  are 
pediculated,  are  of  soft  or  hard  texture,  of  a  rounded,  oval,  or  lobulated 


20  ABNORMITIES    OF    THE 

form,  and  are  invested  with  a  spongy,  ulcerated,  and  often  bleeding 
mucous  membrane. 

Cancerous  morbid  growths  do  not  often  occur,  if  we  except  two  cases 
in  which  a  malignant  tumor  has  made  its  way  into  the  mouth  or  the 
fauces  from  without.  •  Cancerous  degeneration  of  the  tonsils  is  peculiarly 
rare,  and  the  cases  that  have  been  recorded  as  such  have  almost  inva- 
riably proved  to  be  instances  of  mere  hypertrophy  with  induration. 
Still  cancer  of  the  lips,  and  especially  of  the  nether  lip  and  of  the 
tongue,  where  it  chiefly  attacks  the  posterior  half,  is  not  unfrequent ; 
from  these  points  it  branches  out  between  the  muscles  at  the  floor  of  the 
mouth,  at  the  sides  of  the  fauces  down  to  the  neck,  and  on  the  tongue 
it  gives  rise  to  an  irregular,  sinuous,  callous,  and  fungous  ulcer,  which 
is  surrounded  by  an  indurated  margin  of  mucous  tissue. 

§  4.  Anomalies  in  the  Secretions. — We  have,  under  this  head,  to 
notice,  in  addition  to  those  already  spoken  of,  the  different  secretions 
which  cover  the  mucous  membrane  of  the  mouth,  and  especially  of  the 
tongue,  in  various  chronic  and  acute  diseases,  and  the  concretions  occur- 
ring in  the  sinuses  of  the  tonsils.  In  scrofulous  subjects  the  tonsils  are 
often  affected,  in  addition  to  hypertrophy  and  habitual  hyperaemia,  with 
a  peculiar  blennorrhoea,  and  the  purulent  secretion  not  unfrequently 
becomes  inspissated,  so  as  to  form  tubercular  cheesy  plugs,  or  even 
chalky  concretions.  These,  in  their  turn,  keep  up  a  perpetual  state  of 
irritation  in  the  tonsils. 

SECT.  II. — ABNORMITIES   OF  THE   PHARYNX  AND   (ESOPHAGUS. 

§  1.  Defect  and  Excess. — It  is  only  necessary  to  allude  to  the  con- 
genital absence  of  this  passage  as  occurring  in  acephalous  monsters,  to 
its  partial  defect  with  a  blind  termination,  its  fusion  with  the  trachea, 
to  the  saccular  dilatation  of  the  canal  resembling  the  craw  of  a  bird, 
to  its  being  double  in  disomatic  monsters,  and  to  the  very  rare  occur- 
rence of  insulated  fissures  in  individuals  that  are  otherwise  normally  built 
(Meckel). 

§  2.  Acquired  Abnormities  of  the  Calibre,  and  the  thickness  of  the 
Parietes. — Anomalies  of  the  calibre  present  themselves  in  the  shape  of 
dilatations  or  contractions. 

Dilatation  may  affect  the  pharynx  and  oesophagus  throughout,  or 
almost  throughout,  and  give  them  a  cylindrical  or  a  fusiform  appearance ; 
when  it  affects  the  oesophagus,  it  may  be  partial,  in  which  case  either 
pouches  are  formed,  which  involve  all  the  coats  of  the  oesophagus,  and 
which  may  be  developed  at  all  points  of  its  circumference  ;  or  the  mu- 
cous membrane  alone  dilates,  giving  rise  to  diverticula  or  hernias  of  the 
mucous  membrane  through  the  muscular  coat. 

The  first  variety  has  only  been  observed  in  a  few  cases,  though  when 
it  occurs  it  is  developed  to  an  advanced  degree,  and  presents  thicken- 
ing of  the  parietes,  and  particularly  hypertrophy  of  the  muscular  coat. 
It  appears  to  be  sometimes  the  consequence  of  concussion  of  the  oeso- 


PHARYNX    AND    (ESOPHAGUS.  21 

phagus  by  a  blow  or  contusion  of  the  chest.  One  preparation,  in  the 
Viennese  collection,  presents  an  oesophagus  large  enough  to  allow  the 
passage  of  a  man's  arm  ;  in  another  case  (Hanney),  the  circumference 
of  the  dilated  passage  was  six  inches. 

Dilatations  of  a  lower  degree  sometimes  occur,  in  whic^i  the  cesopha- 
geal  coats  are  in  a  condition  of  paralytic  relaxation  and  attenuation. 

The  second  variety  is  seen  at  various  points,  and  in  various  degrees, 
above  contractions,  and  especially  above  scirrhous  strictures. 

The  third  variety  is  rounded ;  or,  if  it  increases  to  a  considerable 
size,  we  find  cylindrical  or  conical  dilatations  of  the  mucous  membrane, 
occupying  the  lateral  portions  of  the  oesophagus.  They  may  form  at 
all  parts  of  the  oesophagus,  but  they  are  most  frequently  seen  near  the 
bifurcation  of  the  trachea,  and  they  attain  the  greatest  size  at  the  in- 
ferior section  of  the  pharynx  (Baillie),  where  the  fibres  of  the  inferior 
constrictor  have  a  horizontal  position.  The  mucous  membrane  is  pro- 
truded between  the  muscular  fibres,  and  becomes  dilated  by  the  food 
that  enters  ;  it  is  at  last  forced  out  in  the  shape  of  a  cylindrical  appen- 
dix, which  lies  between  the  vertebral  column  and  the  oesophagus,  in  a 
line  with  the  axis  of  the  pharynx,  so  that  all  ingesta  pass  into  it,  and 
death  from  starvation  results. 

The  origin  of  the  diverticulum  is  in  many  cases  peculiar ;  thus  we  are 
acquainted  with  an  instance  in  which  the  mucous  membrane  of  the  oeso- 
phagus was  dragged  out  in  consequence  of  the  shrivelling  of  an  adherent 
tracheal  gland. 

The  fauces  and  the  oesophagus  are  not  unfrequently  subject  to  con- 
traction, from  being  compressed  by  the  enlarged  thymus  gland,  by 
aortic  aneurisms,  adventitious  growths,  &c. ;  but  the  contractions  result- 
ing from  textural  changes  in  the  coats  are  of  more  importance,  and 
among  these  we  must  more  particularly  allude  to  stenoses  brought  on 
by  cicatrization  after  corrosion  by  caustic  substances,  and  by  cancerous 
affections  (cancerous  stricture).  Of  both  we  shall  have  further  occasion 
to  speak  in  the  sequel. 

§  3.  Anomalies  of  Position. — Among  these  we  may  reckon  the  posi- 
tion of  the  oesophagus  to  the  right  of  the  spinal  column,  accompanying 
a  lateral  transposition  of  the  intestines,  the  changes  produced  by  cur- 
vatures of  the  spine,  the  flexures  or  dislocations  of  the  pharynx  and 
oesophagus,  brought  about  by  hypertrophy  of  the  thyroid  gland,  by 
aneurisms,  abscesses,  morbid  growths,  &c. 

§  4.  Solutions  of  Continuity. — Among  these  we  reckon,  besides  wounds 
of  the  pharynx  and  oesophagus,  by  means  of  fire-arms,  or  other  pene- 
trating instruments,  the  injuries  and  perforations  caused  by  foreign 
bodies  that  have  been  swallowed,  the  perforations  from  softening,  ulcera- 
tions,  gangrene,  or  from  absorption  in  consequence  of  pressure,  e.  g.,  by 
aneurisms,  by  which  means  the  most  various  passages,  communicating 
with  the  neighboring  serous  cavities,  the  respiratory  organs,  the  adjoin- 
ing vascular  trunks,  &c.,  may  be  established,  and  lastly,  those  very 
rare  occurrences  of  spontaneous  rupture,  without  previous  alteration  in 
the  tissue. 


22  ABNORMITIES    OF 

§  5.  Textural  Diseases.  1.  Inflammation.  —  Catarrlial  inflamma- 
tion : — This  is  rarely  seen  very  intense  in  the  acute,  but  certainly  not 
uncommonly  in  the  chronic  form.  The  appearances  produced  in  that 
case  are  oedema  of  the  mucous  membrane,  with  a  dirty-brown  or  slate- 
colored  tinge,  enlargement  of  the  follicles,  blennorrhoea,  and  an  exu- 
berant formation  of  epithelium,  and  hypertrophy  of  the  muscular  coat. 
It  is  possible  that  when  the  cardiac  orifice  is  the  seat  of  inflammation, 
the  consequent  hypertrophy  of  the  circular  fibres,  and  the  narrowing 
of  the  passage,  may  give  rise  to  those  enormous  dilatations  of  the  oeso- 
phagus, of  which  we  have  already  spoken.  It  frequently  occurs  as  an 
idiopathic,  but  also  as  a  secondary  affection,  and  in  the  latter  case 
chiefly  in  connection  with  impetigo.1 

Croupy  (exudative)  inflammation — occurs  as  an  aphthous  process  in 
children,  as  true  diffused  croup,  coexistent  with,  or  unaccompanied  by, 
croup  of  the  tracheal,  bronchial,  and  pulmonary  (pneumonia)  mucous 
membrane,  mainly  in  typhoid  cholera,  but  also  as  a  secondary  affection 
and  as  an  abortive  exanthematic  and  typhoid  process,  the  product  of  a 
purulent  condition  of  the  blood,  brought  on  by  tubercular  and  cancerous 
cachexia. 

Pustular  inflammation : — To  this  class  belongs  the  rare  occurrence  of 
varioloid  pustules,  the  pustules  of  metastatic  herpes,  and  the  pustules 
which  occur  at  the  lower  third  of  the  oesophagus  in  consequence  of  the 
internal  administration  of  tartar  emetic^in  large  doses. 

In  addition  to  the  above  varieties,  we  meet  with  inflammation,  which 
is  produced  by  the  corrosion  of  caustic  substances ;  the  coexistent  affec- 
tion of  the  oral  cavity  and  the  fauces  being  commonly  of  a  lower,  that 
of  the  gastric  mucous  membrane  of  a'  higher  degree.  We  refer  the 
reader,  for  an  investigation  of  this  process  and  its  consequences,  to  the 
following  pages,  as  we  purpose  examining  it  among  the  diseases  of  the 
stomach,  in  reference  to  all  the  tissues  we  have  alluded  to  ;  at  present 
we  merely  add,  that  in  those  cases  in  which  the  mucous  membrane  has 
been  destroyed  by  the  energetic  action  of  the  poison,  it  is  replaced  by 
a  serous  and  sero-fibrous  tissue,  which  gives  rise  to  peculiar  valvular 
and  annular  strictures  of  the  oesophagus,  somewhat  analogous  to  those 
consequent  upon  dysentery. 

2.  Softening. — Softening  occurs  at  the  lower  third  of  the  oesophagus, 
and  is  commonly  associated  with  softening  of  the  stomach.     On  account 
of  the  identity  of  the  two  affections,  we  refer  the  reader  to  the  section 
on  the  Diseases  of  the  Stomach ;  the  more,  since  the  process  is  observed 
more  frequently  in  the  latter,  if  not  in  a  more  fully  developed  form. 
We  must  however  add,  that  it  is  particularly  liable  to  affect  the  left  side 
of  the  oesophagus,  and  then  to  cause  perforation,  in  consequence  of  which 
we  have  destruction  of  the  cellular  tissue  and  the  left  mediastinum,  and 
effusion  of  the  gastric  contents  into  the  left  pleura. 

3.  Morbid  growths. — a.   Anomalous  fibrous  and  fibro-cartilaginous 
tissue  occurs  as  a  fibroid  or  fibro-chondroid  tumor,  in  the  shape  of  a 

1  [To  render  this  passage  intelligible,  it  may  be  well  to  remind  the  reader  of  the  theory 
very  prevalent  among  German  pathologists,  which  attributes  the  majority  of  chronic  diseases 
to  dormant  or  suppressed  cutaneous  eruptions.  Autenrieth  may  be  mentioned  as  the  chief 
supporter  of  this  doctrine. — ED.] 


THE    PERITONEUM.  23 

movable  bluish-white  concretion,  varying  in  size  from  a  pin's  head  to  a 
kidney  bean,  and  occupying  the  submucous  cellular  tissue  of  the  oesopha- 
gus ;  and  also  as  a  fibrous  polypus,  attached  by  a  neck  to  the  perichon- 
clrium  of  the  cricoid  cartilage,  and  depending  from  it  into  the  oesopha- 
gus ;  the  free  surface  is  frequently  lobulated,  and  it  is  invested  by  mucous 
membrane.1 

b.  Tubercular  deposits  are  rarely,  if  ever,  found  in  the  oesophagus, 
and  they  must  not  be  confounded  with  the  tubercular  degeneration  of  the 
neighboring  lymphatic  glands. 

c.  Carcinoniatous  affections,  in  the  shape  of  scirrhus  and  medullary 
sarcoma,  are  more  frequent.    This  is  generally  a  primary  disease,  though 
the  oesophagus  may  become  secondarily  involved  in  carcinomatous    de- 
generation of  the  mediastina.     In  the  former  case  the  cancer  may  be 
found  in  every  portion  of  the  pharynx  and  oesophagus ;  but  the  upper  part 
of  the  thoracic  portion  of  the  latter,  and  the  inferior  part  of  the  former 
appear  to  be  more  frequently  attacked  than  the  cardiac  portion  of  the 
tube.     The  degeneration  generally  affects  the  circumference  of  the  pas- 
sage, and  thus  gives  rise  to  annular  stricture,  the  extent  of  which  must 
correspond  to  the  extent  of  the  carcinomatous  deposit.     The  oesophagus 
soon  becomes  fixed  by  the  adhesion  of  the  diseased  mass  to  the  spinal 

.column.  The  metamorphosis  of  the  morbid  product  frequently  gives 
rise  to  the  formation  of  large  sanious  cavities,  the  carcinomatous  parietes 
of  which  are  covered  with  fungoid  granulations,  and  with  which  the  oeso- 
phagus communicates  above  and  below  in  a  transverse  or  slanting  direc- 
tion. The  sanious  discharge  frequently  causes  ulcerative  destruction  of 
the  neighboring  tissues,  by  which  means  communications  are  established 
with  the  trachea  and  the  bronchi ;  occasionally  even  the  arterial  coats, 
which  are  otherwise  endowed  with  great  power  of  resisting  such  influ- 
ences, become  involved,  and  communications  with  the  arterial  trunks  in 
the  vicinity,  and  more  especially  with  the  aorta  and  the  right  pulmonary 
artery,  are  established. 

Cancer  of  the  oesophagus  generally  occurs  in  an  isolated  form,  i.  e. 
without  a  coexistence  of  the  disease  in  other  organs. 

§  6.  Foreign  Bodies. — Sometimes  small  hard  bodies,  such  as  cherry- 
stones, give  rise  to  serious  occurrences,  by  causing,  at  different  parts  of 
the  oesophagus,  but  chiefly  at  the  lower  constrictor  of  the  pharynx  (Bail- 
lie),  the  formation  of  diverticula.  Very  large  and  hard  bodies,  such  as 
are  sometimes  swallowed  by  lunatics,  remain  fixed  at  a  certain  spot,  and 
may  cause  inflammation  and  suppuration ;  or,  by  extreme  pressure,  even 
give  rise  to  gangrene  and  perforation  of  the  oesophagus.  Pointed  and 
rough  bodies,  and  especially  needles  and  fish  bones,  are  still  more  likely 
to  produce  perforations  of  the  oesophagus  in  different  directions,  and  to 
reach  the  aorta  or  trachea. 

SECT.  III. — ABNORMITIES    OF   THE    PERITONEUM. 

§  1.  Defect  and  Excess  of  Formation. — Arrest  of  development  in  the 
peritoneal  sac  occurs  in  the  shape  of  fissure  in  the  mesial  line,  or  exter- 

1  Oestr.  Jahrb.  xxi.  2. 


24  ABNORMITIES    OF 

nal  to  it ;  in  the  case  of  the  diaphragm  being  absent,  of  a  fusion  with  the 
pleura ;  as  defective  development  of  the  mesentery  at  various  points, 
as  defective  development  or  complete  absence  of  several  other  folds, 
the  omentum,  the  appendices  of  the  omentum,  as  deficiencies  in  these 
parts,  &c. 

Excess  of  development  frequently  occurs  in  the  shape  of  unusual  length 
of  the  duplicatures,  e.  g.  of  the  omentum,  the  mesenteries,  &c.,  or  of  su- 
pernumerary folds  and  peritoneal  pouches.  These  are  chiefly  found  in 
the  hypogastric,  and  more  especially  in  the  iliac  and  in  the  inguinal  re- 
gions, and  near  the  fundus  vesicse.  There  is  access  to  these  sacs  by  a 
well-defined  fissure  or  ring,  which  is  frequently  surrounded  by  a  tendinous 
band,  lying  in  the  duplicature.  In  the  case  of  their  inclosing  portions 
of  the  intestine,  they  may  give  rise  to  internal  incarceration,  which,  on 
the  one  hand,  resembles  external  hernia,  on  the  other,  does  not  afford 
the  diagnostic  signs  peculiar  to  this  affection,  and  may,  therefore,  be 
considered  as  forming  a  transition  between  external  and  internal  hernia. 
Similar  formations,  such  as  a  delicate  serous  envelope  of  the  small  intes- 
tine, must  be  explained  by  an  original  anomaly  in  the  development  of 
the  peritoneum. 

§  2.  Anomalies  in  the  Size  and  Form  of  the  Peritoneal  Sac. — Among 
these  we  reckon  a  general  increase  of  the  peritoneal  surface,  correspond- 
ing with  a  congenital  enlargement  of  the  abdominal  cavity  and  the  intes- 
tines ;  the  acquired  extension,  which  may  be  uniform,  as  the  result  more 
especially  of  an  accumulation  of  serous  fluid  (ascites) ;  or  partial,  as  pre- 
sented to  us  in  congenital  or  accidental  hernia,  and  in  the  abnormal  size 
or  acquired  elongation  of  single  folds ;  the  latter  are  brought  about  by 
dislocations  of  the  abdominal  contents,  which  arise  spontaneously,  or 
from  a  variety  of  causes,  are  most  frequently  seen  affecting  the  mesente- 
ries and  the  omentum,  and  are  of  signal  importance  in  reference  to  the 
causation  of  internal  hernia. 

A  small  peritoneum  is  the  result  of  an  arrest  of  development  in  the 
abdominal  cavity,  subordinate  to  the  development  of  the  pleura;  an 
apparent  diminution  may  be  caused  by  dislocation  of  the  abdominal  con- 
tents, as  in  large  scrotal  or  diaphragmatic  hernia. 

The  anomalies  of  form  are  involved  in  the  above  anomalies  of  size. 

§  3.  Solutions  of  Continuity. — The  peritoneal  sac  is  liable  to  solutions 
of  continuity  from  penetrating  wounds  of  the  abdomen,  from  the  effect  of 
powerful  concussion,  of  excessive  bodily  exertion,  from  spontaneous  rup- 
tures of  the  hollow  or  parenchymatous  organs  it  invests,  in  consequence 
of  traumatic  injuries,  from  contusion,  rupture,  and  separation  of  the  sub- 
jacent tissues.  The  extent  and  nature  of  the  injury  vary  as  much  as  its 
situation. 

§  4.  Abnormities  of  the  Tissues.  1.  Hypercemia. — Hypersemia  is 
either  general,  or,  when  caused  by  the  congested  state  of  an  organ  in- 
vested by  the  peritoneum,  partial.  It  gives  rise,  on  the  one  hand,  to  an 
increase  of  secretion  and  to  dropsical  accumulations  in  the  peritoneal 
cavity  ;  on  the  other,  to  hypertrophy  and  thickening  of  the  serous  tissue, 


THE    PERITONEUM.  25 

and  to  the  development  of  a  subserous  fibroid  or  fibro-chondroid  growth. 
The  peritoneal  investment  of  the  spleen  offers  the  best  illustration  of  the 
latter. 

2.  Inflammation  (Peritonitis). — Inflammation  of  the  peritoneum  pre- 
sents the  symptoms  common  to  inflammation  of  serous  membranes.  It 
may  occur  as  an  idiopathic  affection,  or  in  consequence  of  traumatic  lesions 
of  the  abdomen,  of  pressure  from  incarceration,  or  from  contact  with  the 
atmosphere,  with  the  contents  of  the  stomach  or  intestines,  with  bile, 
urine,  vaginal  secretions,  blood,  or  pus.  It  may  be  presented  to  us  in 
the  form  of  spontaneous  or  rheumatic  peritonitis ;  it  may  occur  as  the 
result  of  a  propagation  of  disease  from  the  organs  contained  in  the  peri- 
toneal sac.  The  most  frequent  form  is  the  one  attributed  to  metastasis, 
in  which  the  peritoneum,  from  the  large  serous  surface  which  it  offers 
(and  in  this  respect  it  presents  an  analogy  with  the  vast  tract  of  the  in- 
testinal mucous  membrane),  and,  owing  to  its  proximity  in  many  cases 
to  the  primary  seat  of  disease,  is  converted  into  a  focus  of  extensive 
exudative  process.  To  this  class  we  refer  more  particularly  the  inflam- 
matory and  exudative  processes  of  puerperal  fever,  of  which  we  shall 
have  occasion  to  speak  more  fully  at  a  future  period. 

The  affection  is  either  general  or  partial.  In  the  former  case,  it  in- 
volves the  peritoneum  of  the  abdominal  parietes,  of  the  parenchymatous 
viscera,  and  of  the  colon  (enteritis  peritonealis),  though  generally  with  a 
predominance  in  one  or  the  other.  In  both  it  may  appear  in  the  acute 
or  chronic  form. 

A^ute  general  peritonitis  very  often  terminates  fatally,  with  symptoms 
of  intestinal  paralysis,  and  with  imminent  or  existing  ileus ;  or  death  is 
caused  by  exhaustion,  which  gives  rise  to  the  formation  of  large  fibrinous, 
puriform  and  purulent  exudations.  We  then  find,  in  addition  to  the 
symptoms  of  serous  inflammation,  an  enlargement  of  the  intestine  ;  it  is 
expanded  by  gases  (tympanitis),  by  thin  watery  and  feculent  matters ; 
the  coats  of  the  intestine,  and  chiefly  the  interstitial  cellular  tissue  and 
the  mucous  membrane,  are  tumefied,  the  muscular  layer  is  pale,  and  they 
are  all  fragile  and  friable. 

The  tumefaction  of  the  intestinal  coats  is  commonly  owing  to  an  infil- 
tration of  the  tissues  by  a  watery  fluid,  and  increases  in  proportion  to 
the  degree  in  which  the  mucous  membrane  participates  in  the  exuda- 
tive process.  It  occurs  in  the  most  exquisite  degree  in  the  so-called 
metastatic  form,  in  that  inflammation  of  the  peritoneum  which  is  the 
local  expression  of  a  general  disorganization  of  the  blood,  i.  e.  in  the 
puerperal  type.  In  this  case  the  mucous  membrane  presents  a  relation 
similar  to  that  exhibited  by  the  peritoneum  in  exudative  processes  of  the 
mucous  membrane,  in  Asiatic  cholera,  in  colliquative  diarrhoeas  gene- 
rally, or  in  dysentery  in  the  shape  of  a  mucous  secretion,  or  of  a  delicate 
indication  of  plastic  exudation,  evidenced  by  mere  loss  of  brilliancy  and 
smoothness. 

The  ileus,1  which  occurs  in  general  peritonitis,  is,  like  the  dilatation  of 
the  intestine,  the  consequence  of  paralysis  of  the  muscular  coat ;  a  rela- 
tion observed  to  exist  wherever  muscular  fibres  are  subjacent  to  serous 

1  Vide  Oestr.  Jahrb.  xviii.  1. 


26  ABNORMITIES    OF 

membranes.  The  exudation  of  plastic  lymph,  especially  in  the  case  of 
various  abnormal  contortions,  is  also  likely  to  contribute  to  its  occur- 
rence by  binding  down  the  intestine.  We  may  easily  infer  which  will 
be  the  terminal  point  of  the  antiperistaltic  movement,  or  of  ileus,  in  cases 
of  enteritis  peritonealis.  As  the  inflammation  of  the  peritoneum  is  ac- 
companied by  paralysis  of  the  entire  intestine,  it  can  be  no  other  portion 
of  the  intestine  than  the  duodenum,  at  the  lower  end  of  which  the  peri- 
toneum, and  consequently  the  inflammation  and  paralysis,  terminate,  and 
which  by  itself  is,  under  no  circumstances,  capable  of  controlling,  by  its 
peristaltic  action,  the  accumulated  contents  of  the  small  intestines  which 
are  being  thrown  into  it.  Yet  cases  which,  like  puerperal  peritonitis, 
are  generally  accompanied  by  diarrhoea,  form  exceptions  to  this  rule. 

The  exudations  seen  on  the  peritoneum,  exhibit,  in  reference  to 
quantity  and  minute  structure  and  to  their  metamorphoses  generally,  all 
those  variations  which  we  have  cited  in  the  general  remarks  on  inflam- 
mation of  serous  membranes.  The  general  remarks  there  made  with  re- 
gard to  the  acute  and  chronic  forms  of  the  process,  are  equally  applica- 
ble here.  Nevertheless,  we  observe  numerous  peculiarities  in  peritonitis, 
to  which  we  must  here  advert.  We  very  frequently  find  extensive  ca- 
coplastic,  disorganized,  discolored,  septic  exudations,  accompanied  by 
an  almost  imperceptible  increase  of  redness  and  vascularity ;  they  are 
more  especially  associated  with  puerperal,  septic  processes  in  the  uterus. 
Plastic  exudations  become  organized  mt$  cellular  or  cellulo-serous  tissue. 
This  remains  attached  to  the  peritoneum  in  the  shape  of  a  pale,  grayish- 
white,  or  bluish-red  and  vascular,  or  slate-colored  accumulation ;  or  it 
forms  a  new  movable  cellulo-serous  investment  to  all  organs  enveloped 
by  the  peritoneum,  or  it  assumes  the  shape  of  flakes  or  strings,  which 
pass  from  one  to  the  other  in  different  directions.  In  the  two  latter 
cases,  various  tense  or  loose  adhesions  between  the  abdominal  viscera, 
among  themselves,  or  with  the  parietes  of  the  abdomen,  will  result;  of 
these  the  following  are  the  chief: 

Adhesions  of  the  intestinal  coils,  producing  very  manifold  transposi- 
tions among  themselves,  and  with  the  mesentery,  with  the  colon,  in  re- 
ference to  the  hypogastric  parietes  of  the  abdomen  and  the  pelvis,  the 
bladder,  and  the  internal  sexual  organs  of  the  female  ; — adhesions  of  the 
omentum  in  various  degrees  with  the  hypogastric  parietes  of  the  abdomen, 
and  more  particularly  of  the  inguinal  region,  and  with  the  internal  sexual 
organs  of  the  female  ;  the  omentum  may  be  folded  together,  or  rolled  up, 
and  stretched  across  in  a  slanting  direction  to  either  of  the  inguinal  re- 
gions, or  it  may  descend  with  a  furcate  fissure  to  both,  so  as  to  attach 
itself  at  these  points,  and  form  a  vertical,  or,  if  passing  under  the  colon 
transversum,  a  rounded  horizontal  band ;  thus  giving  rise  to  a  species  of 
diaphragm,  which  separates  the  mesogastric  and  hypogastric  regions ; — 
and  adhesions  of  the  parenchymatous  viscera  to  the  adjacent  parietes 
and  to  the  neighboring  viscera. 

Adhesions  between  the  omentum  and  the  colon,  and  the  anterior  pa- 
rietes of  the  abdomen,  are  found  chiefly  in  chronic  peritonitis,  but  they 
are  not  of  frequent  occurrence. 

The  corded  exudations  may,  in  various  ways,  cause  incarcerations  of 
the  intestine. 


THE    PERITONEUM.  27 

Or  the  exudations  undergo  metamorphoses,  so  as  to  give  rise  to  tendi- 
nous or  fibre-cartilaginous  laminae, -sometimes  of  uniform  thickness,  and 
with  defined  edges,  sometimes  of  areolar  or  cribriform  structure,  at  others, 
uneven,  lobulated,  granulated,  thinning  off  towards  the  circumference, 
glued  on  to  or  fused  with  the  thickened  peritoneum.  This  is  remarked, 
principally,  on  the  omentum  and  the  fold  of  the  intestine  in  hernia,  or 
on  the  hernial  sac  itself,  and  also  on  the  convex  surface  of  the  spleen,  on 
the  liver,  sometimes  on  the  uterus  and  its  appendages,  and  in  rare  cases 
on  the  entire  extent  of  the  peritoneum. 

The  chronic  form  of  inflammation,  which  affects  the  exudations  that 
have  already  been  deposited,  and  creeps  on  with  occasional  exacerbations, 
presents  the  following  peculiarities:  It  occupies  the  intestine  only; 
or  at  least  that  part  of  the  circumference  of  the  intestine  chiefly  which 
is  not  affected  hy  adhesions  resulting  from  a  previous  process,  as  well  as 
the  opposed  parietal  surface,  which  in  various  degrees  is  limited  by,  or 
free  from,  adhesions.  The  consequence  is  the  formation  of  a  coagulum, 
which  covers  the  anterior  surface  of  the  already  agglutinated  intestines, 
passing  from  them  to  the  parietes,  and  thus  inclosing  a  sacculated  space 
which  contains  the  fluid  portion  of  the  exuded  matter.  In  such  a  case 
the  intestines,  and  more  particularly  the  small  intestines,  form  a  flattened 
round  mass,  riding  upon  the  vertebral  column,  and  invested  anteriorly 
by  the  posterior  lamina  of  a  pseudo-membrane,  which  contains  in  its 
cavity  a  varying  amount  of  fluid. 

Hemorrhagic  exudation  is  frequently  seen  on  the  peritoneum ;  it  forms 
large,  saturated  coagula,  disposed  in  thick  layers.  Thin  strata  present 
a  deep  black  or  bluish-black  discoloration,  the  effect  of  the  intestinal 
gases. 

Peritonitis  occasionally  terminates  in  suppuration  or  gangrenous  de- 
composition, phthisis  and  gangrcena  peritoncei.  With  the  exception  of 
those  cases,  in  which  purulent  or  gangrenous  disorganization  and  per- 
foration result  from  a  propagation  of  the  disease  from  other  tissues,  this 
termination  occurs  under  the  following  conditions : 

a.  The  peritonitis  itself  yields  a  purulent  exudation,  and  the  perito- 
neum is  destroyed  by  suppuration,  followed  by  the  denudation  and  sup- 
puration of  the  subjacent  tissues.     This  occurs  chiefly  in  partial,  circum- 
scribed peritonitis,  when  the  exciting  causes,  viz.,  suppurative  inflamma- 
tion or  gangrenous  infiltration  of  an  organ,  accompanied  by  a  purulent 
or  ichorous  discharge  on  the  peritoneal  surface,  continue. 

b.  Occasionally  a  certain  portion  of  a  fibrinous  exudation  does  not  be- 
come organized,  but  being  diffused  through  the  interstices  of  the  adven- 
titious membrane,  melts  into  a  creamy  pus,  wbich,  being  in  close  contact 
with  the  latter,  produces  at  once  in  it  and  in  the  peritoneum  suppurative 
inflammation  and  suppuration. 

In  either  case,  ulcerative  perforation  of  the  intestine  or  of  the  ab- 
dominal parietes  frequently  proceeds  from  the  morbid  process  in  the 
peritoneum ;  and  when,  as  is  sometimes  the  case,  both  occur  simultane- 
ously, fistulae  result. 

Partial  peritonitis  in  many  cases  appears  to  be  a  molimen  naturce  des- 
tined to  circumscribe  destructive  processes,  to  arrest  imminent  or  existing 
discharges  which  are  hostile  to  the  integrity  of  the  peritoneum.  To 


28  ABNORMITIES    OF 

these  belong,  first  of  all,  the  circumscribed  inflammations  of  the  peri- 
toneum, which  take  place  in  the  vicinity  of  approaching  or  existing  per- 
forations of  the  stomach,  the  colon,  the  vermiform  process,  in  the  vicinity 
of  purulent  accumulations  external  to  the  peritoneum,  threatening  per- 
foration and  discharge  into  the  peritoneal  cavity,  and  the  like.  By  this 
means,  general  peritonitis,  and  a  consequent  rapid  and  fatal  termination 
are  frequently  postponed  for  a  long  time ;  yet,  whilst  the  exciting  cause 
continues,  peritoneal  phthisis,  with  its  consecutive  disorganization,  must 
ensue ;  or  the  adhesions  which  limit  the  focus  of  inflammation  give  way, 
and,  in  consequence  of  the  free  discharge  of  its  contents,  general  peri- 
tonitis follows,  or  this  may  take  place  without  the  occurrence  first  men- 
tioned, in  consequence  of  the  violence  and  extent  of  the  inflammatory 
process  at  the  original  seat  of  the  disease. 

Gangrene  of  the  peritoneum  occurs  as  a  yellow  slough,  in  consequence 
of  pressure  or  traction  caused  by  external  or  internal  hernia,  in  conse- 
quence of  its  being  deprived  of  the  subserous  cellular  tissue  where  it 
overlays  perforating  ulcers  of  the  intestines  and  abscesses ;  or  as  gan- 
grenous disorganization  and  conversion  into  a  blackish,  moist,  ragged, 
and  friable  tissue. 

3.  Heterologous  formations,  a.  Anomalous  occurrence  of  cellular  and 
of  serous  tissue. — This  appears  on  the  peritoneum  in  the  shape  of  the 
above-mentioned  organizing  processes  of  a  plastic  character,  and  especially 
as  serous  cysts,  in  which  case  the  pseudo-membrane  includes,  during  its 
organization,  a  portion  of  the  fluid  exudation,  and  receives  an  internal 
serous  investment.  Such  bladders  are  either  connected  with  the  peri- 
toneum by  means  of  a  neck  or  stalk,  or  adhere  to  it  by  a  broad  base. 
In  rare  cases  we  find  cysts  with  various  contents  as  new  formations  on 
certain  portions  of  the  peritoneum,  and  then  most  frequently  on  the 
omentum. 

b.  Anomalous  fibrous  (fibro-cartilaginous)  tissue — owes  its  origin  to 
the  inflammatory  process  in  a  similar  manner  as  that  above  described. 
But  there  are,  besides,  other  instances  of  the  occurrrence  of  this  tissue, 
in  the  shape  of  fibro-cartilaginous  smooth  or  lobulated  laminse,  project- 
ing granulations,  &c.,  occupying  the  subserous  layer  of  the  peritoneum. 
They  are  observed  in  old  hernial  sacs ;  rarely,  as  compared  with  the 
pleura,  on  the  parietal,  but  very  frequently  on  certain  portions  of  the 
visceral  plate  of  the  peritoneum,  owing  to  the  hypergemia  which  takes 
place  here,  as,  for  instance,  in  the  case  of  the  spleen.     This  tissue  also 
occurs  in  the  subserous  cellular  tissue  of  the  uterus  and  its  appendages, 
and  on  the  colon  in  the  shape  of  a  fibroid  growth ;  in  the  former  case,  it 
reaches  a  considerable  magnitude  :  in  the  latter,  it  rarely  exceeds  that 
of  a  lentil  or  a  pea. 

c.  Anomalous  osseous  tissue — is  developed  from  the  above-mentioned 
tissue  in  the  shape  of  compact,  smooth,  or  uneven  lobulated  plates  of 
varying  thickness.     The  fibroid  growth  in  the  subserous  cellular  tissue 
of  the  intestinal  canal  is  very  rarely  the  seat  of  ossification. 

d.  Tubercle. — Tuberculosis  of  the  peritoneum  occurs  in  the  various 
forms  of  which  we  gave  a  general  sketch  when  treating  of  the  tuber- 
cular disease  of  serous  membranes,  both  as  an  acute  and  as  a  chronic 
affection. 


THE    PERITONEUM.  29 

It  is  very  frequently  found  in  the  circumscribed  form  on  those  parts 
of  the  peritoneum  which  correspond  with  tubercular  ulcers  of  the  mucous 
membrane  ;  and  we  here  trace  all  the  forms  peculiar  to  peritoneal  tuber- 
culosis generally.  It  commonly  does  not  appear  until  the  secondary 
tubercular  infiltrations  have  extended  from  the  inner  surface  of  the  intes- 
tinal tube  into  the  muscular  coat,  and  thus  involved  the  tissue  of  the 
peritoneum  itself. 

The  tubercular  exudations  on  the  peritoneum  likewise  give  rise  to  all 
the  adhesions  we  have  above  spoken  of,  generally  producing  a  more  inti- 
mate agglutination  between  the  viscera.  Peritoneal  tuberculosis  occa- 
sionally appears  as  a  primary  affection,  the  peritoneum  being  the  first 
tissue  attacked  by  tubercular  deposit ;  but  it  occurs  more  frequently  after 
the  cachexia  has  been  evidenced  by  tuberculosis  of  another  organ.  Thus 
it  allies  itself  to  pulmonary,  intestinal,  and  cerebral  tubercle,  and  it  very 
commonly  terminates  in  tubercular  affections  of  the  abdominal  lymphatic 
glands,  and  in  the  female  sex  more  particularly  in  tuberculosis  of  the 
uterine  and  vaginal  mucous  membrane.  The  acute  forms  of  peritoneal 
tuberculosis  are,  in  most  cases,  complicated  with  a  corresponding  affec- 
tion in  the  spleen,  the  liver,  the  kidneys. 

The  reflected  action  upon  the  adjacent  muscular  fibre,  which  occurs  in 
peritoneal  inflammation,  is  presented  to  us  in  a  much  higher  degree  in  the 
tubercular  exudative  process.  "We  find  that  the  intestinal  coats,  in  addi- 
tion to  being  tumefied,  become  very  friable  ;  there  is  increased  exhala- 
tion from  the  inner  surface  of  the  intestine,  and  liquefaction  of  its  con- 
tents, the  muscular  coat  becomes  pale,  is  easily  lacerated  and  broken  up, 
and  even  the  muscles  of  the  abdominal  parietes  waste  and  lose  color. 

Peritoneal  tubercle,  and  especially  the  granulated  variety,  rarely  passes 
into  the  stage  of  softening  ;  when  it  does  so,  it  may  cause  tubercular 
suppuration  or  peritoneal  phthisis,  and  consequently  phthisis  of  other 
adjacent  tissues ;  cretification  is  a  still  more  unusual  occurrence,  but  the 
tubercular  disease  frequently  becomes  stationary. 

e.  Carcinoma. — The  peritoneum  is  either  secondarily  affected  by  car- 
cinoma, a  cancerous  growth  originally  generated  externally  to  it,  ap- 
proaching and  involving  it  in  its  metamorphosis,  perforating  it  and  pene- 
trating into  its  cavity  ;  or  the  carcinoma  is  produced  without  such  ante- 
cedents, though  commonly  occasioned  by  a  carcinomatous  affection  in  the 
neighborhood,  in  the  vicinity  of  which  it  is  formed ;  or,  lastly,  it  occurs 
in  some  rare  cases,  altogether  independently  of  such  causes,  as  a  primary 
affection  of  the  peritoneum.  It  must,  therefore,  with  the  exception  of 
the  last-mentioned  unfrequent  case,  be  considered  as  the  product  of  can- 
cerous cachexia  which  has  already  found  a  nidus  and  a  local  habitation. 

The  most  common  form  of  carcinoma,  into  which,  however,  the  other 
carcinomatous  growths,  which  give  rise  to  its  appearance  on  the  perito- 
neum, usually  degenerate,  is  the  areolar,  and,  second  in  order,  the  me- 
dullary species. 

The  former  appears  as  a  hard,  crystalline,  transparent,  and  discrete 
cancerous  follicle,  resembling  tubercle,  and  of  the  size  of  a  hemp  or  millet 
seed ;  in  the  acute  variety  it  is  generally  thickly  sown  over  a  large  ex- 
tent, and  even  spreads  over  the  entire  peritoneum,  or  it  occurs  as  a  layer 
of  areolar  cancerous  tissue,  varying  in  thickness,  or  as  a  circumscribed, 


30  ABNORMITIES    OF 

round,  lobulated  aggregation.  The  omentum  is  very  commonly  found  to 
shrivel  up  and  to  degenerate  into  a  transverse  band,  or,  in  the  opposite 
case,  with  an  enormous  increase  of  size,  into  areolar  cancer. 

Medullary  carcinoma  frequently  occurs  in  the  acute  form,  as  the  white 
or  colored  (melanosis)  encephaloid  variety,  either  deposited  in  layers,  or 
more  commonly  as  compressed,  rounded,  medullary  nodules,  of  different 
dimensions. 

In  the  fibro-carcinomatous  degeneration  of  the  peritoneum  and  its 
subserous  cellular  tissue,  which  occasionally  extends  over  the  entire  peri- 
toneum, we  invariably  perceive  an  atrophy  and  condensation  of  the  tissues, 
and,  in  consequence,  a  contraction  of  the  carcinomatous  folds  of  the  peri- 
toneum, e.  g.  in  the  mesentery. 

Peritoneal  cancer  is  commonly  complicated,  in  the  manner  above  de- 
scribed, with  gastric  intestinal  and  ovarian  cancer,  and  then  also  with 
uterine  and  hepatic  cancer,  the  medullary  form  prevailing  in  the  latter 
case.  We  must  not  omit  to  allude,  at  this  place,  to  the  nodulated 
retro-peritoneal  cancerous  formations  of  Lobstein,  which  commonly  take 
their  origin  in  the  glands  of  the  lumbar  plexus  or  other  subordinate  por- 
tions of  the  absorbent  system,  and  which  extend  into  the  mesentery. 

§  5.  Morbid  Contents  of  the  Peritoneal  Cavity. — In  reference  to  this 
subject  we  may  direct  the  reader  to  the  preceding  remarks,  to  the  general 
investigation  of  the  abnormities  of  serous  membranes,  and  to  subsequent 
paragraphs.  At  this  place  we  merely  allude  to  the  presence  of  gas 
(meteorismus  abdominals)  and  of  serous  fluid  (ascites)  in  the  peritoneal 
cavity.  The  former  occurs  in  rare  cases  as  a  joint  product  of  the  inflam- 
matory process,  or  as  the  result  of  decomposition  affecting  an  exudation 
of  low  vitality,  and  in  extremely  rare  cases  as  the  product  of  a  deranged 
secretion  ;  but  it  is  more  frequently  a  mere  extravasation  of  intestinal  gas, 
resulting  from  rupture,  gangrene,  ulceration,  or  softening  of  the  stomach 
or  intestine. 

Extensive  accumulation  of  serous  fluid  gives  rise  to  ascites.  It  is  very 
often  the  result  of  an  hydropic  cachexia,  dependent  upon  a  variety  of 
causes,  and  is  then  commonly  associated  with  other  dropsies.  In  the 
first  instance,  the  predominant  hydropic  symptom  is  mostly  the  conse- 
quence of  granular  liver,  heart-affections,  frequently  of  Bright's  disease 
of  the  kidneys ;  it  accompanies  carcinomatous  formations  on  the  peri- 
toneum, &c. 

SECT.   IV. — ABNORMITIES   OF  THE  STOMACH. 

§  1.  Original  arrest  of  development  of  the  stomach  involving  at  the 
same  time  a  large  portion  of  the  intestinal  canal  is  found  in  very  imper- 
fect monstrosities,  and  more  particularly  in  acephalous  foetuses, — the 
stomach  is  occasionally  absent  in  individuals  otherwise  normally  built 
and  provided  with  a  well-developed'  intestinal  tube,  or  it  may  only  be 
indicated  by  a  small  saccular  dilatation  of  the  oesophagus. 

§  2.  Deviations  of  Size. — Congenital  malformations  belonging  to  this 
class,  are  either  unusual  enlargement,  or  unusual  diminution  of  size ;  the 
latter  peculiarly  affecting  the  female  sex. 


THE    STOMACH.  31 

Either  of  these  conditions,  but  chiefly  the  abnormal  increase  in  size, 
occur  likewise  as  acquired  diseases. 

Dilatation  of  the  stomach  is  either  spontaneous,  or  it  is  caused  by 
stenosis.  The  former  variety  presents  a  uniform  increase  of  size,  and 
sometimes  acquires  such  a  surprising  extent,  as  to  fill  the  entire  abdomi- 
nal cavity.  Repeated  repletion,  in  consequence  of  a  morbid  appetite, 
may  give  rise  to  this  development,  or  it  may  occur  as  a  result  of  para- 
lysis from  concussion,  traction,  or  dislocation  produced  by  large  scrotal 
hernke,  and  it  kills  slowly  with  vomiting,  with  or  without  gangrene  of  the 
mucous  membrane,  under  symptoms  of  complete  paralysis. 

Dilatation  from  stenosis  varies  according  to  the  seat  of  the  latter.  In 
common  stenosis  of  the  pylorus,  it  is  mainly  developed  at  the  splenic 
portion  ;  it  equally  reaches  an  enormous  degree,  and  proves  at  last  fatal 
by  paralysis.  When  stenosis  occurs  at  a  different  spot,  more  or  less  con- 
siderable saccular  dilatations  take  place  in  other  sections  of  the  stomach, 
and  in  different  directions. 

A  diminution  of  the  stomach  is  sometimes  produced  as  a  permanent 
condition  in  consequence  of  an  insufficient  supply  of  nutriment;  in 
other  cases  it  is  the  consequence  of  textural  disease,  especially  that 
produced  by  cicatrization  of  extensive  ulcers.  Contractions  or  stenoses 
are  the  result  of  hypertrophy  of  the  gastric  membranes,  of  carcinoma, 
particularly  when  occurring  at  the  pylorus,  and  of  cicatrization  after 
ulcerative  destruction  of  the  tissue  at  this  and  at  other  points. 

In  reference  to  the  thickness  of  the  parietes  of  the  stomach,  we  may 
observe,  that  extreme  thickness,  not  connected  with  degeneration  of  the 
tissues,  is  the  immediate  consequence  of  the  hypertrophy  of  one,  or 
more  commonly  of  both  of  the  internal  coats.  The  pyloric  region  is 
chiefly  liable  to  the  affection,  which  is  sometimes  limited  to  the  annular 
portion ;  it  is  developed  to  a  greater  extent  when  resulting  from  stenosis 
of  the  pylorus,  accompanied  by  the  above-described  dilatation,  and  it 
then  affects  mainly  the  muscular  fibres.  Hypertrophic  disease  of  the 
pylorus  must  be  carefully  distinguished  from  carcinomatous  thickening. 

Attenuation  of  the  gastric  coats  not  unfrequently  occurs  at  the  fundus 
in  consequence  of  extreme  dilatation  of  the  stomach  resulting  from 
stenosis  of  the  pylorus.  The  thinning  which  occurs  as  spontaneous 
atrophy,  or  tabes,  with  or  without  an  accompanying  change  in  the  capa- 
city of  the  stomach,  is  of  greater  importance ;  it  is  a  very  rare  and 
tedious  disease,  but  one  which  we  have  invariably  seen  associated  with 
universal  tabes,  and  with  atrophy  of  the  lungs  (emphysema  senile)  and 
the  heart. 

§  3.  Deviations  of  Form. — Among  these  we  reckon,  first  of  all,  those 
rare  congenital  malformations  of  the  human  stomach,  in  which  an 
annular  contraction  divides  it  into  a  cardiac  and  pyloric  stomach,  or  in 
which  two  or  three  such  contractions  form  three  or  four  sacculated  divi- 
sions, and  thus  cause  a  resemblance  to  the  stomach  of  ruminants.  We 
distinguish  these  from  the  contractions  produced  during  the  agony  of 
death,  by  the  fact  that  the  latter  may  be  removed  by  inflating  the 
stomach. 

Similar  and  various  other  malformations  are  observed  as  acquired 


32  ABNORMITIES    OF 

conditions ;  they  have  their  origin  mainly  in  loss  of  substance  and  in 
cicatrization  of  the  so-called  perforating  gastric  ulcer,  and  we  shall 
recur  to  the  subject  when  we  discuss  the  latter. 

§  4.  Deviations  of  Position.  Congenital. — Position  of  the  stomach 
external  to  the  abdominal  cavity  in  eventration,  and  in  umbilical  hernia ; 
in  the  left  side  of  the  thorax,  the  diaphragm  being  wholly  or  partially 
absent  on  this  side ;  vertical  (foetal)  position,  with  the  pylorus  down- 
wards ;  the  position  of  the  fundus,  in  the  right  hypochondrium,  corre- 
sponding to  the  reversion  of  the  formative  type  in  lateral  translocation. 
Acquired. — Protrusion  of  the  stomach,  externally,  in  consequence  of 
extensive  penetrating  wounds,  or  into  the  thorax,  after  injuries  to  or 
rupture  of  the  diaphragm ;  the  position  of  the  stomach  in  large  hernial 
sacs,  especially  of  umbilical  and  scrotal  hernia ;  the  dislocation  of  the 
stomach  from  its  natural  position  by  enlargement  of  the  organs  in  its 
vicinity,  by  morbid  products,  by  effusion  into  the  peritoneal  cavity,  by 
traction  of  the  omentum  and  transverse  colon ;  lastly,  the  spontaneous 
sinking  of  the  entire  stomach  into  a  lower  abdominal  region  from  increase 
of  volume  or  weight,  as  in  the  case  of  a  scirrhous  pylorus. 

§  5.  Solutions  of  Continuity. — We  merely  allude  here  to  those  rare 
occurrences  of  wounds  of  the  stomach  produced  by  penetrating  instru- 
ments, and  by  firearms,  occasionally  healing  up  with  a  fistulous  opening, 
and  to  those  circumscribed  separations  bf  the  membranes  of  the  stomach 
from  one  another,  accompanied  by  extravasation  of  blood,  which  occa- 
sionally result  from  concussion. 

§  6.  Diseases  of  the  Tissues. — As  we  have  already  treated  of  the 
diseases  of  the  peritoneum,  we  shall  now  discuss  those  of  the  gastric 
mucous  and  submucous  tissues,  and  the  consecutive  affections  of  the 
muscular  coat  of  the  stomach. 

1.  Inflammation,  a.  Catarrh  of  the  gastric  mucous  membrane  (gas- 
tritis mucosa). — The  opportunity  of  observing  the  first  stages  of  the 
genuine  acute  catarrh  of  the  gastric  mucous  membrane,  of  the  gastric- 
saburral,  gastric-bilious,  and  allied  conditions,  in  the  dead  subject,  is 
rarely,  if  ever,  offered ;  we  see  the  blennorrhagic  stage,  chronic  catarrh, 
and  the  occasional  acute  exacerbations  of  the  latter,  more  frequently. 

The  latter  is  developed  from  repeated  active  hypersemia,  or  from 
lasting  mechanical  hyperaemia,  and  the  gastric  catarrhs  observed  in 
gourmands,  and  especially  in  drunkards,  and  accompanied  by  ulceration, 
and  by  the  formation  of  morbid  products  in  the  stomach  in  chronic 
heart  disease,  or  in  pulmonary  phthisis,  are  particularly  remarkable. 
The  latter  are  generally  complicated  with  catarrh  of  the  entire  intestinal 
tract,  and  with  bronchial  catarrh. 

The  anatomical  signs  of  this  condition  are,  a  dark,  reddish-brown,  or 
slate-gray,  or  even  blackish-blue  discoloration  of  the  mucous  membrane, 
copious  secretion  of  a  stone-colored,  occasionally  glassy  pituita,  thicken- 
ing, increased  condensation  and  induration,  i.  e.,  hypertrophy  of  the 
mucous  membrane,  which  presents  itself  in  various  degrees : 


THE    STOMACH.  33 

a.  In  the  lowest  degree,  the   mucous   membrane   shows   simply  an 
increase  of  thickness  and  hardness  in  its  tissue ; 

/5.  In  a  higher  degree,  it  presents,  in  addition  to  its  increased  thick- 
ness, an  uneven,  racemose,  or  warty  surface,  a  surface  mamellonee; 

Y.  In  a  still  more  advanced  degree,  it  forms  prolongations  in  the 
shape  of  permanent,  firm  folds,  or  of  polypus. 

The  submucous  cellular  tissue,  and  the  muscular  coat,  also  participate 
in  this  hypertrophy  in  various  degrees — the  entire  parietes  of  the  sto- 
mach presenting  unusual  thickness,  firmness,  and  hardness. 

The  pyloric  portion  is  the  chief  seat  of  chronic  catarrh,  and  it  is 
there  that  hypertrophy  of  the  mucous  and  other  membranes  is  most 
prominent. 

b.  Croupy  inflammation. — This  form  never  occurs  as  a  primary  and 
substantive  affection  except  in  the  shape  of  delicate  flocculent  exuda- 
tions in  the  aphthous  process  of  children,  but  always,  and  even  that 
rarely,  as  a  sequela  or   degeneration   of  exanthematic   processes,   in 
variola,  in  typhus,  in  the  absorption  of  pus  into  the   circulation,  and 
particularly  in  puerperal  inflammation  of  the  uterine  veins.     The  false 
membrane  which  sometimes  invests  the  entire  stomach,  presents  a  very 
regular  areolar  surface. 

The  operation  of  tartar  emetic  upon  the  gastric  mucous  membrane 
may  produce  a  similar  process,  it  is  however  commonly  limited  to  a  few 
streaks. 

c.  Inflammation  of  the  submucous  cellular  tissue. — Idiopathic  inflam- 
mation of  the  submucous    cellular  tissue  of  the  stomach,    resembling 
pseudo-erysipelas,  and  passing  on  to  suppuration,  is  a  very  rare  pheno- 
menon ;  it  not  unfrequently  occurs  as  a  secondary  process,  analogous  to 
the  metastases  of  specific,  acute  dyscrasise.     The  parietes  of  the  stomach 
appear  thickened ;  the  stratum  of  submucous  tissue  is  distended  with 
pus ;  it  is  soft  and  friable ;  the  superincumbent  mucous  membrane  is 
reddened,  and,   at  intervals,  tense.     After  a  time  it  gives  way  at  these 
points,  and,  by  numerous  irregular  cribriform  openings,  the  pus  exudes 
into  the  cavity  of  the  stomach. 

d.  The  process,  which  is  caused  by  the  operation  of  caustic  substances 
on  the  membranes  of  the  upper  part  of  the  alimentary  canal. 

We  limit  ourselves  to  a  statement  of  the  modus  operandi  of  the  more 
common  substances  which  are  taken  accidentally,  or  are  administered  as 
poisons,  such  as  the  mineral  acids,  and  especially  the  sulphuric  acid  of 
the  shops,  and  white  arsenic,  and  give  the  results  afforded  by  numerous 
post-mortem  examinations. 

The  effect  of  the  mineral  acids  generally  extends  over  the  cavity  of 
the  mouth  and  fauces,  the  gullet,  the  oesophagus,  the  stomach,  and  occa- 
sionally beyond  the  latter ;  sometimes  it  is  limited  to  the  former,  so 
that  scarcely  a  trace  is  visible  in  the  stomach. 

In  reference  to  the  intensity  of  the  effect  which  may  cause  superficial 
or  deep  mortification  of  the  tissues  with  greater  or  less  rapidity,  we 
distinguish  several  degrees.  The  effect  is  influenced  by  the  quantity 
and  the  strength  of  the  liquid,  and  the  duration  of  the  period  during 
which  it  remained  in  contact  with  the  parts  alluded  to.  We  generally 
find  the  effect  to  be  less  intense  in  the  cavity  of  the  mouth  and  fauces, 

VOL.  II.  3 


34  ABNORMITIES    OF 

more  marked  in  the  oesophagus,  and,  provided  an  appreciable  amount 
of  acid  reached  the  stomach,  most  powerful  at  this  point.  In  the  lowest 
degree  the  effect  is  limited  to  destruction  of  the  epithelium.  The  mucus 
of  the  mouth  and  the  fauces  contains  flocculent  coagula ;  the  epithelium 
is  converted  into  a  thick,  grayish-white,  rugose  layer ;  it  peels  off  here 
and  there,  and  the  subjacent  mucous  membrane  is  pale. 

In  an  advanced  degree,  the  superficial  layers  of  the  mucous  membrane 
of  the  fauces  and  oesophagus,  under  the  destroyed  epithelium,  are  found 
corrugated,  of  a  dirty,  whitish,  leaden  hue,  and  the  capillary  network 
blackened  by  its  carbonified  contents.  The  lowrer  strata  of  the  mucous 
membrane,  and  the  submucous  cellular  tissue,  present  serous  infiltration. 
In  the  follicles  at  the  root  of  the  tongue,  the  mucous  secretion  is  coagu- 
lated into  dirty  white  masses. 

In  a  still  higher  degree,  the  entire  mucous  membrane  is  destroyed,  and 
converted  into  a  dirty  gray  mass,  which  is  traversed  by  black  vessels ; 
the  submucous  cellular  tissue  is  infiltrated,  and  partially  ecchymosed  ; 
the  muscular  coat  of  the  oesophagus  itself  is  shrivelled,  pale,  ashy. 

In  the  highest  degree,  the  mucous  membrane  of  the  oesophagus,  together 
with  the  submucous  cellular  tissue,  is  converted  into  a  soft,  black  mass, 
which  is  distended  by  a  sanguinolent  fluid,  and  is  easily  detached  from 
the  muscular  coat.  The  latter  is  itself  either  destroyed  in  the  same  man- 
ner, or  is  perfectly  colorless,  friable,  and  presents  an  ashy,  gelatinous 
appearance.  ^ 

The  mucous  membrane  of  the  stomach  almost  invariably  suffers  the 
changes  of  the  third  degree,  though  in  varying  extent  and  thickness.  It 
is  either  affected  in  single  folds,  or  streaks  which  pass  from  the  cardiac 
orifice  to  the  lesser  curvature,  and  from  the  large  curvature  to  the  pylo- 
rus ;  or  over  a  large  extent ;  or  we  find  the  entire  surface  converted  into 
a  black  carbonaceous  mass,  of  several  lines  in  thickness,  distended  by 
sanguinolent  fluid,  and  consequently  presenting  a  tumefied  appearance. 
The  muscular  coat  is  altered  in  the  manner  peculiar  to  the  third  degree, 
and  we  therefore  often  find  the  parietes  of  the  stomach  perforated. 

The  acid  affects  the  neighboring  organs  through  the  membranes,  and 
thus  either  coagulates  or  tans  the  contained  fluids,  fuses  the  tissues  into 
a  gelatinous  mass,  or  carbonifies  them ;  the  discoloration  produced  is 
always  very  marked.  In  many  cases,  not  only  the  blood  of  the  neigh- 
boring bloodvessels,  but  also  of  the  larger  trunks,  and  even  of  the 
aorta,  is  changed  into  pultaceous,  pitchy,  greasy,  black  cylinders.  Beyond 
the  stomach,  and  especially  in  the  duodenum,  and  at  the  commencement 
of  the  jejunum,  the  effect  of  the  lowest  degree  is  exhibited  in  coagulation 
of  the  intestinal  mucus,  and  of  the  chyle,  in  corrugation  and  opacity  of 
the  epithelium,  in  the  tanned  state  of  the  mucous  membrane,  and  the 
dark  injection  of  its  vessels.  The  consequences  and  results  are  modified 
according  to  the  intensity  of  the  operating  influence. 

The  highest  degrees,  in  which,  generally,  a  very  extensive  surface  is 
involved,  produce  a  rapidly  fatal  termination.  The  lowest  degrees  are 
followed  by  exudative  inflammation  ;  the  mortified  epithelium  sloughs, 
and  being  replaced  by  a  new  formation  as  soon  as  the  reaction  has  abated, 
recovery  ensues. 

In  all  the  higher  degrees  we  have  reactive  inflammation  in  the  healthy 


THE    STOMACH. 


35 


tissue,  which  effects  the  rejection  of  the  superincumbent  mortified  tissue 
by  passing  into  suppuration.  As  the  inflammatory  and  suppurating  pro- 
cesses diminish,  the  tissues  contract,  cicatrices  form,  and  a  cure  results  ; 
or  suppuration  is  protracted,  causing  a  late  recovery,  or  ending  fatally 
in  oesophageal  phthisis. 

According  to  the  depth  to  which  the  tissues  are  destroyed,  the  loss  of 
substance  is  repaired  under  a  formation  of  strictures,  that  vary  in  size 
and  consistency. 

If  the  mortification  be  limited  by  the  submucous  cellular  tissue,  we 
shall  find  the  latter  condensed  over  the  pale,  ashy,  muscular  coat,  which 
now  resembles  the  elastic  tissue,  into  a  serous,  or  fibro-serous,  tissue, 
replacing  the  mucous  membrane  to  a  considerable  extent.  This  tissue 
forms,  at  some  places,  projecting  ridges,  or  valvular,  and  even  annular, 
duplications  towards  the  oesophagus ;  and  we  thus  have  a  peculiar  mem- 
branous stricture  of  the  latter  produced,  not  unlike  the  strictures  found 
in  dysentery. 

If  the  muscular  coat  itself  is  involved,  it  is  partially  or  entirely  de- 
stroyed, and  the  walls  of  the  oesophagus  are  converted  into  a  fibro-cellular 
firm  tissue,  which  contracts,  and  thus  produces  the  most  important  and 
most  resisting  strictures. 

These  strictures  are  formed  chiefly,  though  not  exclusively,  at  the 
lower  section  of  the  pharynx,  posterior  to  the  cricoid  cartilage,  and  in 
the  vicinity  of  the  cardiac  portion.  We  also  not  unfrequently  see, 
besides  these  strictures,  solitary  insulated  remains  of  the  mucous  mem- 
brare  on  the  inner  surface  of  the  oesophagus,  in  consequence  of  the  con- 
traction of  the  new  tissues.  They  have  a  shrivelled  appearance,  and  are 
in  part  detached,  or  form  transverse  bands. 

A  torpid  suppurative  process  is  commonly  the  result  of  a  more  pro- 
found injury,  and  is  seen  in  the  shape  of  abscesses  and  sinuses  of  the 
muscular  coat,  and  of  the  condensed  cellular  sheath  of  the  oesophagus. 
When  it  ceases,  it  invariably  leaves  very  considerable  contraction  of  the 
tissues  and  strictures  of  the  kind  last  described ;  ulcerative  perforation  of 
adjoining  passages  (trachea,  bronchi)  may  follow ;  death  frequently  ensues 
from  phthisis,  or  by  exhaustion  from  dysphagia. 

The  same  occurrences  may,  though  less  frequently,  be  observed  in  the 
membranes  of  the  stomach. 

The  operation  of  arsenic  is  limited  to  the  mucous  membrane  of  the 
stomach,  but  it  frequently  produces  no  local  effect ;  and  this  is  parti- 
cularly the  case  where  the  symptoms  of  poisoning  and  death  follow  rapidly 
after  the  introduction  of  small  quantities.  When  present,  it  is  an  exu- 
dative inflammatory  process,  accompanied  by  softening  and  sloughing. 
At  one  or  more  points,  to  which  a  white  pulverulent  substance  (arsenic) 
happens  to  attach  itself  to  a  larger  amount,  the  mucous  membrane  ap- 
pears plicated  and  tumefied,  reddened,  invested  by  a  detached  epithelium, 
and  a  tawny  exudation  ;  its  tissue  is  softened,  pultaceous  ;  and  at  the  spot 
where  the  white  grains  of  arsenic  are  attached,  it  is  converted  into  a 
yellowish  or  greenish-brown  slough.  Between  these  solitary  foci,  from 
which  reddened  folds  of  the  mucous  membrane  proceed,  the  inner  surface 
of  the  stomach  presents  at  many  parts  a  perfectly  normal  structure. 

2.    Ulcerative  processes. — The  ulcerative  loss  of  substance  which  results 


36  ABNORMITIES    OF 

from  one  or  the  other  of  the  processes  we  have  hitherto  considered,  re- 
quires no  separate  examination,  as  it  presents  nothing  characteristic. 
There  are  other  ulcerative  affections  of  the  stomach  which  appear  of  more 
importance.  Those  connected  with  tubercular  and  cancerous  affections 
we  shall  examine  under  the  head  of  tubercle  and  carcinoma.  At  present 
we  consider  the  following  : 

a.  The  perforating  ulcer  of  the  stomach. — There  is  one  kind  of  ulcer 
that  occurs  in  the  stomach,  which,  both  on  account  of  its  frequency,  and 
on  account  of  the  extreme  pain  it  causes,  as  well  as  on  account  of  the 
numerous  and  enigmatical  symptoms  that  accompany  it,  deserves  every 
attention, — an  ulcer,  termed  by  Cruveilhier  the  simple  chronic  ulcer  of 
the  stomach,  and  which  we  would  call  the  perforating  gastric  ulcer,  from 
its  prevailing  tendency  to  perforate  the  parietes  of  the  stomach. 

In  a  well-defined  case  there  is,  in  the  region  of  the  pylorus,  a  circular 
orifice  of  from  three  to  six  lines  in  diameter,  with  a  sharp  peritoneal  edge, 
as  if  a  round  piece  of  the  gastric  parietes  had  been  punched  out.  When 
viewed  from  within,  the  loss  of  substance  on  the  internal  membranes  of 
the  stomach,  and  especially  on  the  mucous  layer,  appears  more  consider- 
able, so  that  the  edges  of  the  hole  seem  bevelled  off  from  within  outwards. 
There  is  no  further  morbid  appearance  beyond  a  thickening  of  the  parietes 
in  the  immediate  neighborhood  of  the  ulcer,  and  a  tumefaction  of  the 
gastric  mucous  membrane. 

The  pyloric  half  of  the  stomach  is  the  seat  of  the  ulcer ;  it  is  most 
frequently  found  in  the  middle  zone  of  this  portion ;  it  is  oftener  seen  at 
the  posterior  than  at  the  anterior  surface,  almost  always  near  to,  and 
frequently  at,  the  lesser  curvature ;  and  it  occurs,  in  extremely  rare  cases 
only,  at  the  fundus.  This  affection  may  also  appear  beyond  the  stomach 
in  the  upper  transverse  portion  of  the  duodenum,  but  it  does  not  occur 
in  the  remaining  portion  of  the  intestinal  canal. 

The  size  of  the  ulcer  varies  from  that  of  a  sixpence  to  that  of  half-a- 
crown,  and  even  to  that  of  a  cheese-plate. 

Its  shape  is  commonly  circular,  but,  in  exceptional  cases,  it  is  from  the 
beginning  of  an  irregular  form,  though  the  circular  form  with  which  it 
commences  frequently  disappears  subsequently.  Ulcers  of  great  extent 
approach  the  elliptical  shape ;  but,  on  further  extension,  this  too  is  lost, 
and  they  become  irregular  in  consequence  of  the  formation  of  sinuses 
varying  in  depth.  The  extension  of  the  ulcer  in  the  transverse  diameter 
of  the  stomach,  so  as  to  form  a  zonular  ulcer,  is  singular,  on  account  of 
the  deformity  of  the  stomach  which  follows.  The  original  form  of  the 
ulcer  is  also  lost,  when  two  ulcers  coalesce  so  as  to  form  a  single  one. 
In  these  cases  we  may  for  a  long  time  be  able  to  point  out  the  boundaries 
of  each,  represented  by  a  ridge  of  cellular  tissue,  but  this,  too,  will  dis- 
appear, and  they  then  both  have  the  same  common  base. 

In  the  majority  of  cases  there  is  only  a  single  ulcer,  but  frequently 
there  are  two  or  three,  occasionally  four  or  five,  and  these  are  then  com- 
monly placed  above  or  near  to  one  another  at  the  posterior  surface  of 
the  stomach,  or  at  the  lesser  curvature.  It  is  very  rarely  the  case  that 
one  occurs  at  the  posterior,  and  the  other  at  the  anterior  surface  of  the 
stomach,  or  that  two  ulcers  are  formed  opposite  to  one  another  in  the 
duodenum. 


THE    STOMACH.  37 

It  has  not  been  clearly  ascertained  in  what  shape  the  malady  takes  its 
origin,  and  in  what  manner  the  further  development  is  effected.  It  is 
probable  that  it  commences  with  an  acute,  circumscribed,  red  softening 
(hemorrhagic  erosion),  or  with  a  circumscribed  sloughing  of  the  mucous 
membrane ;  it  is  still  more  probable  that  the  ulcer  increases  in  this  man- 
ner, the  tissues  at  the  base  of  the  ulcer  sloughing  and  exfoliating  layer 
by  layer.  We  have  observed  this  occurrence  in  a  few  solitary  instances, 
and  wre  would  therefore  view  the  process  as  offering  a  valuable  analogy 
to  sloughing  of  the  lungs  (gangrsena  pulmonalis)  ;  on  the  other  hand,  we 
cannot  admit  that  view  to  be  well  grounded,  which  explains  the  loss  of 
substance  in  question  solely  by  the  absorptive  process ;  the  callosities  of 
the  surrounding  tissues,  and  the  well-marked  reaction  at  the  base,  are  in 
themselves  sufficiently  strong  arguments  against  it. 

The  ulcer  attacks  the  deeper-seated  parts  in  a  peculiar  manner,  when 
it  presents  the  perfectly  round  form.  The  loss  of  substance  is  more  ex- 
tensive in  the  mucous  membrane  ;  if  the  muscular  coat  has  been  attacked 
and  destroyed,  we  find  a  smaller  ring  with  sharp  edges,  and  the  ulcer 
thus  obtains  a  peculiar  scarped  appearance.  If,  finally,  the  peritoneum 
is  perforated,  this  point  will  occupy  the  centre  of  the  circle  ;  the  serous 
membrane  will  be  converted  into  a  yellow  slough,  and  it  will  tear,  or  be 
voided. 

This  process  may  run  an  acute  course ;  but  it  is  commonly  chronic  ; 
occasionally  it  comes  to  a  standstill,  and  then  again  exacerbates  in  an 
acute  or  chronic  form.  A  cure  may  result  at  any  of  the  stages,  as 
pro  red  by  the  various  cicatrices  frequently  observed  on  the  inner  surface 
of  the  stomach.  Even  actual  perforation  of  the  stomach  is  frequently 
rendered  innocuous  by  the  adhesion  of  neighboring  organs,  and  complete 
cicatrization  may  follow. 

Loss  of  substance  in  the  mucous  membrane  alone  is  repaired  by  a  con- 
densation of  the  submucous  cellular  tissue  into  a  fibro-cellular  tissue, 
which  causes  the  edges  of  the  mucous  membrane  to  approach  one  another, 
and  is  finally  blended  with  it  and  the  muscular  coat.  A  radiated,  aste- 
roid scar,  varying  in  size,  remains. 

When  the  ulcerative  process  has  involved  the  muscular  coat,  and  has 
penetrated  beyond  it,  the  muscular  fibres  that  edge  the  ulcer  retract  be- 
yond the  mucous  membrane,  the  subserous  cellular  tissue  and  the  perito- 
neum shrivel  up,  the  walls  of  the  stomach  forming  the  bases  of  the  ulcer, 
and  now  only  consisting  of  these  two  layers,  are  doubled  inwards,  the 
divided  portions  of  the  mucous  membrane  are  thus  brought  together,  and 
a  union  is  gradually  effected.  We  then  find  corded  cicatrices,  which 
shorten  the  stomach  in  its  transverse  diameter,  or  form  annular  contrac- 
tions proportionate  to  the  extent  of  substance  destroyed  or  to  their 
position.  The  pylorus  is  particularly  liable  to  a  diminution  of  its  calibre. 

Perforation  and  its  temporary  or  permanent  cure,  demands  a  more 
minute  exposition. 

If  it  takes  place  at  a  portion  of  the  stomach,  which,  like  the  greater 
part  of  the  anterior  gastric  parietes,  but  rarely  enters  into  a  protective 
adhesion  with  neighboring  tissues,  perforation  allows  the  contents  of  the 
stomach  to  pass  freely  into  the  peritoneal  cavity,  and  fatal  peritonitis 
follows. 


38  ABNORMITIES    OF 

This  result  is  frequently  prevented.  Whilst  we  find  the  tolerably 
uniform  irritation  within,  giving  rise  to  hypertrophy  of  the  mucous  mem- 
brane and  to  callosity  of  the  base  of  the  ulcer  and  its  circumference,  we 
see  at  the  corresponding  points  of  the  peritoneal  surface,  cellular  adhe- 
sions, or  a  more  intimate  union  between  the  stomach  and  the  reverted 
omentum,  the  left  hepatic  lobe,  or  the  pancreas,  produced  by  repeated, 
circumscribed,  inflammatory  attacks.  The  cellular  adhesions  which  have 
been  effected  between  the  stomach  and  the  omentum,  and  are  sometimes 
found  to  unite  the  former  with  the  left  lobe  of  the  liver,  are  not  sufficient 
to  prevent  a  fatal  issue  when  perforation  occurs,  for  as  soon  as  this  event 
has  taken  place,  the  adhesions  inflame, — this,  and  the  forcible  expulsion 
of  the  gastric  contents,  loosens  and  tears  them,  and  thus  the  inflamma- 
tion spreads  to  the  peritoneum,  both  by  continuity  of  tissue,  and  by 
direct  contact.  The  perforation  will  be  rendered  more  permanently  in- 
nocuous by  intimate  adhesion,  viz.,  by  the  agglutination  of  a  fibro-carti- 
laginous  exudation ;  as  this  tissue  offers  to  the  contents  of  the  stomach, 
both  from  its  density  and  its  thickness,  a  sufficiently  firm  resistance. 
This  frequently  occurs  between  the  small  curvature,  or  the  anterior  sur- 
face of  the  stomach,  and  the  concavity  of  the  left  lobe  of  the  liver,  and 
very  frequently  between  the  posterior  gastric  surface,  the  pancreas,  and 
the  adjoining  lymphatic  glands ;  but  very  rarely  between  the  posterior 
surface  of  the  stomach  and  the  spleen,  after  the  latter  has  been  dragged 
into  that  position,  or  between  the  stomach  and  the  diaphragm  (Aber- 
crombie,  Chardel).  In  such  cases,  after  £he  external  membranous  layers 
have  been  destroyed  to  an  extent  proportionate  to  the  loss  of  substance, 
the  mucous  membrane  is  invariably  doubled  back  over  the  edge  of  the 
perforating  ulcer,  and  impinges  upon  the  pseudo-membranous  aggluti- 
nating tissue  external  to  the  stomach ;  thus  the  orifice  in  the  gastric 
parietes  is  never  filled  up  by  the  superimposed  tissue  in  such  a  manner 
as  to  be  flush  with  the  inner  surface  of  the  stomach,  or  even  to  project 
beyond  it  into  the  cavity  of  the  latter. 

In  favorable  but  rare  cases  the  pseudo-membranous  tissue  contracts 
and  draws  the  edges  of  the  orifices  together,  so  as  to  produce  a  firm, 
callous  cicatrix. 

In  other  instances  this  does  not  occur ;  the  cavity,  though  covered  in 
as  described,  remains,  and  particularly  when  adjoining  the  pylorus,  in 
consequence  of  the  vis  a  tergo  of  the  gastric  contents,  enlarges  into  a 
lateral  sinus,  which  is  lined  by  the  false  membrane. 

Although  in  the  majority  of  cases  a  free  opening  of  the  stomach  is 
thus  prevented,  we  may  even  here  find  exceptions  ;  the  soldering  tissue 
may  itself  gradually  be  consumed,  the  adjoining  organ  is  laid  bare,  and 
becomes  exposed  to  an  extension  of  the  process.  Thus  we  have  seen  one 
case  in  which  the  adjacent  diaphragm,  which  had  formed  a  plug,  was 
perforated  from  the  stomach,  and  the  base  of  the  adhering  lung  was  at- 
tacked. 

In  the  progress  of  the  perforating  gastric  ulcer  a  very  important 
occurrence  frequently  supervenes,  viz.,  hemorrhage,  which  often  kills  on 
the  first,  but  more  frequently  after  repeated  attacks.  So  long  as  the 
ulcer  has  not  perforated  the  walls  of  the  stomach,  the  loss  of  blood  is  in- 
considerable, as  the  process  involves  only  the  small  vessels  of  the  mem- 


THE    STOMACH.  39 

branes,  which  are  easily  plugged  up.  But  as  soon  as  the  ulcer  has 
penetrated  through  the  gastric  parietes,  it  meets  with  larger  vessels  in 
and  beyond  the  pseudo-membranous  layer,  or  with  the  vascular  system 
of  the  obturating  organ.  Thus,  the  trunks  of  the  splenic,  the  coronary, 
the  pyloric,  the  gastro-epiploic,  the  gastro-duodenal  arteries  and  their 
branches,  and  more  especially  those  going  to  the  pancreas,  are  corroded 
and  opened,  and  exhausting  and  fatal  hemorrhages  ensue. 

Bloodvessels  are  not  alone  involved  in  the  destructive  process,  but 
other  canals  also,  and  we  instance  the  pancreatic  ducts,  which,  in  the 
case  to  which  we  allude,  open  upon  the  base  of  the  ulcer,  and  by  forming 
pancreatic  fistula,  oppose  the  complete  consolidation  of  the  imperfect 
cicatrix. 

The  ulcer  not  only  proves  fatal  by  perforation,  with  consequent  peri- 
tonitis and  hemorrhage,  but  also,  though  rarely,  by  exhaustion  from 
dyspepsia  and  harassing  cardialgia.  It  is  invariably  accompanied  by 
chronic  catarrh  and  blennorrhcea  of  the  gastric  mucous  membrane  ;  it 
heals  as  we  have  remarked,  very  frequently,  but  it  as  often  recurs.  The 
cure  of  large  ulcers  is  followed  by  considerable  deformities  of  the 
stomach,  and  more  especially  by  shortening  of  the  posterior  wall  and  the 
lesser  curvature,  or  by  annular  structures.  The  disease  occurs  chiefly 
at  the  period  of  puberty,  and  very  often,  particularly  in  the  female  sex, 
as  early  as  the  15th  year. 

The  perforating  gastric  ulcer  is  in  no  way  connected  with  gastritis 
and  cancer,  though  it  is  often  mistaken  for  these  affections ;  but  it  is 
important  to  know,  though  it  be  for  the  mere  cadaveric  diagnosis,  that 
in  rare  cases  it  may  be  complicated  with  cancer ;  yet  it  always  retains 
its  peculiar  characters  so  as  to  be  distinguishable  in  the  midst  of  the 
cancerous  growth  and  devastation. 

(b.)  Hemorrliagic  erosion  of  the  gastric  mucous  membrane. — Very 
frequent  opportunities  are  presented  to  us  of  observing  loss  of  substance 
accompanied  by  bleeding,  in  the  mucous  membrane  of  the  stomach. 
There  are  round  or  roundish  spots  of  the  size  of  a  pin's  head  or  a  pea, 
or  narrow,  elongated  streaks,  at  which  the  mucous  membrane  appears 
dark  red,  lax,  soft,  bleeding,  and  presenting  a  depression  in  consequence 
of  loss  of  substance  or  slight  erosion. 

Commonly  a  dirty  brown  coagulum  is  attached  to  the  point,  and  the 
nature  of  the  derangement  only  becomes  evident  after  the  coagulum  has 
been  removed.  Sometimes  this  loss  of  substance  involves  the  entire 
thickness  of  the  mucous  membrane  and  the  submucous  cellular  tissue, 
and  produces  an  appearance  of  small,  round,  or  striated  ulcers. 

This  process  is  invariably  accompanied  by  hemorrhage ;  the  gastric 
mucus,  which  generally  is  present  in  considerable  quantity,  presents 
streaks  of  discolored  blood,  proportionate  to  the  number  of  diseased 
points,  or  it  shows  a  copious  admixture  of  brown  flocculi  or  debris,  or 
we  find  an  accumulation  of  fluid  in  the  stomach,  resembling  coffee- 
grounds.  The  entire  mucous  membrane  is  found  in  a  condition  of  recent 
or  inveterate  blennorrhoea  and  catarrh,  and  in  the  vicinity  of  the  ero- 
sions it  is  often  tumefied  so  as  to  form  a  vallated  circumference. 

The  number  of  these  erosions  varies  ;  it  not  unfrequently  happens  that 
the  stomach,  with  the  exception  of  the  fundus,  is  closely  studded  with 


40  ABNORMITIES    OF 

them,  and  is  marked  with  red  or  brown  spots,  according  to  the  color  of 
the  adherent  coagula. 

They  occur  at  every  period  of  life — they  are  seen  even  in  the  infant, 
and  they  are  found  chiefly  at  the  pyloric  portion,  i.  e.  in  that  part  which 
is  the  chief  seat  of  the  catarrhal  process.  The  follicles,  or  the  glandular 
apparatus  of  the  gastric  mucous  membrane  (Cruveilhier's  gastritis  folli- 
culosa),  appear  to  be  their  occasional  nidus. 

This  inflammation  and  erosion  undoubtedly  occur  sometimes  as  an 
idiopathic  affection.  They  are  more  commonly  developed  consequent, 
or  attendant  upon  the  most  diverse,  acute,  and  chronic  diseases,  so  that 
no  definite  conclusion  as  to  the  real  nature  of  the  process,  and  as  to  its 
connection  with  other  affections,  has  yet  been  arrived  at.  An  acquain- 
tance with  the  fact  is  of  considerable  importance,  though  it  only  serves 
to  assure  us  that  the  disease  is  idiopathic,  and  in  no  way  allied  to  the 
erosion  produced  by  caustic  substances. 

3.  Softening  of  the  Stomach. — We  must  distinguish  two  primary  forms 
of  softening,  which  present  essential  differences  in  numerous  points ; 
both,  however,  are  to  be  carefully  distinguished  from  cadaveric  softening, 
the  self-digestion  of  the  stomach. 

The  one,  a  disease  of  infant  life,  is  called  gelatinous  softening.  It 
appears  to  be  a  metamorphosis — a  softening — of  the  mucous  membrane 
of  the  fundus,  which  extends  to  the  muscular  coat  and  the  peritoneum, 
converting  them  and  the  intervening  interstitial  cellular  tissue,  into  a 
grayish  or  grayish-red  transparent  jelly}  with  a  yellowish  tinge,  through 
which  single  dark-brown  streaks,  the  broken-down  bloodvessels,  are  ob- 
served to  pass.  Inasmuch  as  the  softened  inner  strata  occasionally  be- 
come detached,  the  fundus  of  the  stomach  may  be  found  to  consist  of 
nothing  else  but  thin,  gauze-like,  friable  portions  of  the  peritoneum. 

The  softened  portion  of  the  stomach  tears  at  the  slightest  touch ;  it 
dissolves  between  the  fingers,  and  perhaps  in  rare  cases  these  rents  occur 
during  life,  but  probably  oftener  after  death,  giving  rise  to  effusion  of  the 
gastric  contents  into  the  abdominal  cavity. 

The  process  is  not,  however,  limited  to  the  stomach,  but  frequently 
extends  to  the  neighboring  tissues,  and  chiefly  to  muscular  organs,  and 
especially  to  the  diaphragm.  Here,  too,  perforation  is  the  final  result, 
and  with  it  there  is  effusion  of  the  gastric  contents  into  the  left  pleura. 

Gelatinous  softening  of  the  stomach  commonly  runs  a  subacute  course : 
general  anaemia,  which  is  particularly  apparent  throughout  the  intestinal 
canal,  and  general  collapse  and  wasting,  which  are  chiefly  evident  in  the 
muscular  tissue,  are  constant  accompaniments  of  this  disease.  It  is  fre- 
quently founded  upon  a  demonstrable  affection  of  the  brain,  principally 
hypertrophy,  or  hydrocephalus  :  and  this  fact  renders  it  probable  that 
there  is  a  similar  causative  nexus  in  those  cases  also,  in  which  no  visible 
anomalies  have  been  hitherto  detected  in  the  infantine  brain.  Perhaps 
the  proximate  cause  may  be  looked  for  in  diseased  innervation  of  the 
stomach,  owing  to  a  morbid  condition  of  the  vagus,  and  to  extreme  acidi- 
fication of  the  gastric  juice. 

Nevertheless,  the  qucestio  vexato  as  to  the  origin  of  the  affection  in 
irritation  or  inflammation  remains.  If  we  consider,  in  addition  to  the 
above  remarks,  the  uniform  localization  of  the  disease,  that  in  none  of  its 


THE    STOMACH.  41 

stages  it  presents,  either  at  the  point  of  the  softening  or  in  its  vicinity, 
hyperaemia,  injection,  or  reddening,  and  that  we  are  still  less  able  to 
demonstrate  upon  the  inner  surface  of  the  stomach,  or  in  the  tissue  of 
its  coats,  the  products  of  inflammation,  we  are  constrained  to  infer  the 
non-inflammatory  nature  of  the  affection.  This  conclusion  gives  a  key 
to  the  various  kinds  of  softening  that  occur  at  advanced  periods  of  life 
under  similar  circumstances,  viz.,  in  cerebral  affections. 

A  second  form,  in  which  softening  of  the  stomach  takes  place,  is  dis- 
tinguished by  an  absence  of  pallor  in  the  softened  tissues,  or  rather  by 
their  color.  The  parietes  of  the  stomach  are  converted  into  a  more  or 
less  saturated  dark-brown,  or  blackish  pulp. 

It  occurs  under  two  different  circumstances,  though  in  both  the  process 
has  an  acute  character,  and  in  both  the  color  of  the  softening  tissues  is 
produced  by  an  alteration  of  the  blood  contained  in  them,  by  an  acid. 
They  differ  essentially  in  their  genetic  relations. 

In  the  first  instance,  it  occurs,  both  in  children  and  adults  as  a  sequela 
of  acute  affections  of  the  brain  and  its  membranes,  and  more  especially  of 
tubercular  meningitis  at  the  base  of  the  brain.  It  is  the  same  process  as 
gelatinous  softening  of  the  stomach,  and  the  theory  to  which  we  have 
alluded  is  the  more  applicable  the  more  fully  the  affection  at  the  base  of 
the  cerebrum  is  developed.  But  the  development  takes  place  with  the 
greater  rapidity,  the  less  the  acute  disease  of  the  brain  has  induced  that 
degree  of  anaemia  which  commonly  prevails  in  gelatinous  softening  ;  and, 
the  tissue  being  still  more  or  less  injected,  the  superabundant  acid  acting 
upon  the  contained  blood,  produces  the  characteristic  discoloration.  The 
solitary  fuliginous  streaks  above  alluded  to,  as  occurring  in  the  pale,  jelly- 
like  membranes  of  the  stomach,  are  analogous  to  this  condition.  Besides, 
it  not  unfrequently  presents  itself  in  those  cases  of  pulmonary  paralysis 
which  are  probably  caused  by  a  reflex  action  of  the  oesophageal  and 
gastric  branches  of  the  vagus. 

In  the  second  instance,  the  softening  occurs,  unconnected  with  the 
etiological  relations  we  have  hitherto  discussed,  under  totally  different 
circumstances.  We  now  speak  of  it  as  a  sequela  of  certain  cachexiae, 
which  were  either  originally  acute,  or  became  so  under  the  influence  of 
certain  circumstances,  viz.,  the  exanthematic,  the  croupy,  the  typhoid  in 
the  widest  senses,  pyaemia,  acute  tuberculosis,  acute  cancer — it  is  then  to 
be  viewed  as  a  fatal  degeneration  of  these  diseases.  This  form  is  developed 
from  a  congestion  in  the  capillary  network  of  the  gastric  membranes,  and 
particularly  of  the  mucous  membrane  of  the  fundus,  which  is  generally 
accompanied  by  a  more  or  less  congested  state  of  the  spleen.  It  pro- 
bably arises  from  the  state  of  the  blood  itself  which  accumulates  with  an 
excess  of  acid  in  the  vascular  system  of  the  fundus,  and  of  the  spleen. 
This  too  is  the  cause  of  the  generally  rapid  course  of  the  affection,  the 
dark  color  of  the  softened  tissues  and  their  frequent  perforation.  It 
commences  with  a  dark  brown  or  black  discoloration  of  the  mucous  mem- 
brane at  the  fundus,  which  is  soon  converted  into  a  black  pulp  that  may 
easily  be  detached.  If  it  be  removed  or  if  it  separate  spontaneously,  a 
pale,  bluish-white,  submucous  cellular  tissue  is  exhibited,  in  which  ves- 
sels ramify  whose  coats  are  disorganized,  and  which  contain  a  black  (car- 
bonified)  granular  coagulum.  The  subjacent  muscular  coat  is  pale  and 


42  ABNORMITIES    OF 

thin,  the  peritoneum  dull,  and  of  a  dirty  gray  color.  The  process  ex- 
tends from  the  mucous  membrane  to  the  subjacent  tissues :  they  are  con- 
verted into  a  black,  grumous  pulp,  and  thus  more  or  less  extensive  per- 
forations result,  which  are  bounded  by  a  furred  margin.  Here,  too,  the 
diaphragm  is  frequently  involved,  and  softening  and  perforation  of  this 
organ  follow.  The  stomach  is  found  to  contain  large  quantities  of  fluid 
resembling  coffee-grounds  or  ink,  which  is  often  vomited  during  life — 
there  is  an  admixture  of  more  or  less  of  the  softened  tissues,  and  of  their 
fat,  which  floats  in  the  mass  in  the  shape  of  oil-globules.  This  fluid 
originates  in  the  sanguineous  effusion  which  takes  place  at  the  com- 
mencement of  the  disease  ;  the  latter  proceeding  from  the  vascular  sys- 
tem, and  first  affecting  the  coats  of  the  vessels.  On  the  occurrence  of 
perforation,  the  fluid  is  extravasated  into  the  peritoneum,  and  into  the 
left  pleura  ;  and  it  here  gives  rise  to  a  similar  process  in  the  serous  mem- 
brane, accompanied  by  the  evolution  of  gas. 

In  rare  cases  this  process  only  takes  place  at  solitary,  circumscribed 
spots,  and  does  not  then  appear  to  run  its  course  so  rapidly.  The  mu- 
cous membrane  disappears  at  these  points,  with  the  exception  of  a  very 
thin,  gauze-like,  discolored  layer,  to  the  edges  of  which  are  attached  a 
few  jagged  remains  of  the  former. 

The  fundus  is  the  seat  of  all  the  softening  processes  of  the  stomach — 
from  here  they  extend  to  the  large  curvature  of  the  stomach,  in  which 
respect  they  differ  from  the  gastric  diseases  that  we  have  already  con- 
sidered, or  that  we  are  about  to  examine,  such  as  catarrhs,  follicular  ero- 
sions, the  perforating  ulcer,  hypertrophy,  cancer.  It  is  there  too  that 
we  find  the  perforations ;  and  it  is  only  in  very  rare  cases  that  we  see 
softening  at  the  large  curvature  precede  the  development  of  softening  at 
the  fundus. 

Softening,  and  especially  the  last-named  form,  occurs  in  company  with 
softening  of  the  fundus  at  the  oesophagus.  The  lower  third  of  this  tube 
is  liable  to  be  attacked,  and  the  side  which  is  directed  towards  the  left 
side  of  the  thorax  is  chiefly  so,  as  the  perforations  almost  invariably 
occur  here,  producing  effusions  into  the  left  half  of  the  thorax,  after 
the  cellular  sheath  of  the  oesophagus  and  the  mediastinum  have  been 
absorbed. 

The  softening  is  never  distinctly  circumscribed,  but  is  shaded  off  gra- 
dually into  the  surrounding  tissues.  It  is  a  fact  of  considerable  import- 
ance, that  softening  may  take  place  after  death  from  the  operation  of 
cadaveric,  chemical  changes,  which  closely  resemble  the  processes  we 
have  just  described.  It  is  not  always  easy  to  decide  between  this  self- 
digestion  and  morbid  softening ;  nay,  it  is  a  matter  of  impossibility  for 
the  conscientious  pathologist,  unless  he  take  the  previous  disease  and  the 
mode  of  death  into  consideration. 

The  following  circumstances  may,  however,  serve  to  characterize  cada- 
veric softening : 

a.  The  absence  of  all  symptoms  during  life  which  indicated  softening, 
or  the  morbid  processes  that  gave  rise  to  it. 

b.  Sudden  death,  from  natural  or  other  causes,  during  the  digestive 
act,  whilst  the  stomach  is  filled  with  chyme,  without  previous  illness. 


THE    STOMACH.  43 

c.  Limitation  of  the  softening  to  the  mucous  membranes,  and  espe- 
cially to  the  projecting  folds,  so  as  to  form  streaks. 

cL  And  at  the  same  time  its  extension  beyond  the  ordinary  boun- 
daries of  morbid  softening — its  development  being  most  remarkable  at 
those  points  at  which  there  is  a  stagnation  of  the  greatest  quantity  of  the 
gastric  contents. 

4.  Heterologous  formation,  a.  Anomalous  occurrence  of  fatty  tissue, 
of  lipomatous  tumors  between  the  gastric  membranes^  and  chiefly  in  the 
submucous  cellular  tissue. — These  growth's  project  into  the  cavity  of  the 
stomach,  being  either  attached  by  a  neck  or  sessile,  and  being  invested 
by  mucous  membrane.  Occasionally  they  pass  through  the  fasciculi  of 
the  muscular  coat,  and  present  similar  tumors  under  the  peritoneum. 

b.  Anomalous  fibrous  andfibro-cartilaginous  tissue — appears  chiefly  in 
the  vicinity  of  the  cardiac  orifice  and  the  lesser  curvature,  and  assumes 
the  shape  of  flattish,  roundish,  whitish,  tough  concretions  in  the  cellular 
tissue,  which  are  movable  and  of  the  size  of  a  lentil  or  pea. 

c.  Erectile  tissue — is  either  developed  at  the  free  end  of  polypi,  or 
the  mucous  membrane  degenerates  into  it  on  a  larger  surface,  upon 
which  the  erectile  tumor  is  attached  by  a  broad  base,  or  only  by  a  very 
short  neck  or  stalk.     It  is  the  common  seat  of  encephaloid  infiltration. 

d.  Tubercle  and  tubercular  ulceration  of  the  stomach — are  a  very  rare 
occurrence,  and  primary  tuberculosis  of  the  stomach  is  almost  unknown. 
It  commonly  occurs  as  a  result  of  intestinal  tuberculosis  which  has  ad- 
vanced to  an  extreme  degree ;  the  tubercular  ulcers  extend  from  the 
ileum  through  the   jejunum  and  duodenum  into  the  stomach.     They 
here  are  generally  limited  to  the  pyloric  portion,  but  sometimes  extend 
to  the  fundus.     The  remarks  we  shall  have  to  make  on  intestinal  tubercle 
apply  also  to  the  original  seat  of  tubercle  and  the  character  of  the  tuber- 
cular ulcer  in  the  stomach.     In  the  former  the  mesenteric,  in  the  latter, 
the  lymphatic  glands  are  the  seat  of  tubercular  affections,  and  we  may 
use  this  as  an  aid  to  the  diagnosis  of  a  gastric  ulcer,  the  characters  of 
which  may  not  otherwise  be  sufficiently  defined. 

e.  Carcinoma. — Carcinomatous  diseases  affect  the  stomach  very  fre- 
quently, and  carcinoma  of  the  stomach  is  moreover  the  most  common 
carcinomatous  disease  of  the  digestive  tube.     It  must  be  carefully  dis- 
tinguished, as  we  shall  have  occasion  to  explain  more  fully,  from  mere 
hypertrophy,  the  non-malignant  thickening  of  the  gastric  membranes, 
with  which  it  is  sometimes  confounded. 

"We  find  all  the  different  species  of  carcinoma,  the  fibrous,  the  medul- 
lary, the  areolar,  occurring  at  this  point ;  though  in  various  degrees  of 
frequency.  Fibrous  cancer  is  the  most  common,  the  pure  genuine  me- 
dullary cancer  less  so,  and  the  areolar  variety  is  very  rare.  Often  enough 
we  find  the  first  two,  and  sometimes  all  three,  occurring  in  primary,  but 
more  particularly  in  secondary,  combination. 

a.  Fibrous  cancer  appears  as  thickening  of  the  submucous  cellular 
stratum,  which  congeals  into  a  resisting,  whitish,  fibro-lardaceous  mass, 
and  unites  intimately  with  the  mucous  and  the  muscular  coats.  The 
latter  becomes  pale,  and  gradually  undergoes  a  change  which  is  charac- 
teristic of  all  kinds  of  cancer.  It  increases  in  thickness,  and  at  the  same 
time  degenerates  into  a  pale  yellowish-red  areolar  tissue,  the  interstices 


44  ABNORMITIES    OF 

of  which  are  filled  up  by  a  slightly  translucent  and  apparently  crystal- 
line substance.  The  increase  of  the  muscular  coat  is  uniform,  whereas 
that  of  the  submucous  cellular  tissue  is  commonly  irregular,  and  we  thus 
see  lobulated  protuberances  formed  on  the  inner  surface  of  the  stomach. 

Fibrous  cancer  is  the  one  most  easily  and  most  frequently  co-founded 
with  hypertrophy  of  the  gastric  coats.  The  distinguishing  signs  aYe,  the 
preponderating  increase  of  substance  in  the  submucous  cellular  tissue 
and  its  want  of  uniformity,  the  accompanying  cartilaginous  hardness 
and  closeness  of  texture,  the  fusion  with  the  mucous  and  muscular  coats, 
and  particularly  the  alteration  in  the  muscular  tissue  just  described  (John 
Miiller). 

The  mucous  membrane  itself  undergoes  further  peculiar  changes.  It 
sometimes  degenerates  into  an  areolar  cancerous  tissue,  which  dis- 
charges large  quantities  of  a  gelatinous  mucous  fluid ;  or  it  is  converted 
into  erectile  tissue,  as  a  fungoid  growth,  which  becomes  the  seat  of 
encephaloid  infiltration,  suppurates,  and  partially  exposes  the  submucous 
scirrhous  cellular  tissue ;  or  lastly,  it  most  frequently  becomes  the  seat 
of  a  sloe-black  softening  with  hemorrhage,  and  we  thus  find  the  scirrhous 
submucous  cellular  tissue  invested  by  a  thin,  gauze-like  black  remnant 
of  the  mucous  membrane,  or  it  is  quite  denuded,  merely  retaining  here 
and  there  a  few  solitary  black  convolutions  of  vessels  at  its  surface. 

The  scirrhus,  too,  at  once  becomes  the  seat  of  various  metamorphoses. 
It  may,  after  it  has  been  denuded  of  its  mucous  membrane,  become  gan- 
grenous in  large  patches  or  in  round  circumscribed  spots,  the  tissue  ex- 
foliating by  layers,  so  as  to  give  rise  to  deep,  smooth  excavations  in  the 
crude  cancer ;  or  it  may  become  developed  into  a  more  highly-organized 
carcinomatous  formation,  such  as  medullary  sarcoma,  accompanied  by 
bleeding  fungoid  tissue ;  this  is  soon  destroyed  by  a  suppurative  pro- 
cess, leaving  an  ulcer  which  is  surrounded  by  an  elevated  lardaceous 
margin. 

/?.  Medullary  cancer  of  the  stomach  occurs  independently  of  its  secon- 
dary appearance  in  the  metamorphosis  of  fibrous  cancer,  primarily  in 
various  forms : 

aa.  In  the  shape  of  soft  and  even  liquid,  milky,  medullary,  infiltration 
of  the  erectile  tissue,  into  which  the  mucous  membrane  has  degenerated, 
the  other  coats  remaining  normal  (vide  p.  43). 

(30.  As  a  lardaceous,  medullary  degeneration  of  the  submucous  cellular 
stratum  to  a  greater  extent. 

YY-  As  knotted  tumors  between  the  gastric  coats,  and  here  too  chiefly 
in  the  submucous  cellular  tissue. 

Medullary  carcinoma  is  distinguished  in  this  form  also,  by  its  extensive 
growth,  and  by  its  rapid  metamorphosis,  accompanied  by  vascular  fun- 
goid degeneration. 

f.  Areolar  cancer  presents,  in  the  degeneration  of  the  mucous  and 
submucous  cellular  tissues,  the  characters  generally  peculiar  to  this  form. 

We  often,  as  has  been  remarked,  find  these  varieties  of  cancer  occur- 
ring simultaneously  ;  in  the  stage  of  metamorphosis  in  which  more  par- 
ticularly a  consecutive  complication  is  seen,  the  fibrous  cancer  at  the  base 
gives  rise  to  an  areolar  cancer,  from  which,  in  its  turn,  medullary  cancer 
shoots  up  in  the  shape  of  a  peripheral  erectile  growth. 


THE    STOMACH.  45 

The  stomach  is  either  the  primary  or  the  secondary  seat  of  disease. 
In  the  former,  the  most  usual  case,  the  cancerous  degeneration  extends 
from  the  stomach  to  other  organs,  attacking  the  lymphatic  glands  which 
are  contiguous  to  the  head  of  the  pancreas  and  the  biliary  ducts,  the 
pancreas  itself,  the  glands  of  the  lumbar  plexus,  and,  finally  the  fibrous 
investments  of  the  vertebral  column,  the  liver,  the  transverse  colon,  the 
omentum,  &c.  In  the  latter  case,  which  is  of  much  less  frequent  occur- 
rence, the  stomach  is  secondarily  attacked,  the  morbid  affection  commenc- 
ing in  neighboring  tissues,  and  particularly  in  the  conglomerations  of 
lymphatic  glands,  from  which  it  extends  to  circumscribed  portions  of  its 
posterior  parietes.  In  this  variety,  the  cancerous  ulcer  may  proceed 
beyond  the  stomach,  establishing  communications  with  the  transverse 
colon  or  with  other  portions  of  the  intestine,  and  it  may  even  force  its 
way  outwards  after  a  previous  union  of  the  stomach  and  the  abdominal 
parietes  has  been  effected,  and  the  latter  have  been  destroyed. 

The  pylorus,  indifferently  at  all  parts  of  its  circumference,  is  known 
to  be  the  chief  seat  of  primary  fibrous  and  areolar  cancer  of  the  stomach. 
From  this  point  the  degeneration  extends  chiefly  along  the  lesser  curva- 
ture over  the  pyloric  half  of  the  stomach ;  in  many,  though  rarer  cases, 
it  affects  the  entire  stomach,  attacking  the  fundus  last,  which  however 
generally  remains  partially  free.  The  parietes  of  the  stomach  may 
attain  an  inch  in  thickness,  being  rigid  and  generally  tuberculated  on 
their  inner  surface  ;  the  cavity  of  the  stomach  will  at  the  same  time  be 
diminished  in  size.  The  cardiac  orifice  of  the  stomach  is  rarely  the  seat 
of  cancerous  degeneration,  and  it  is  singular  that  cancer  of  the  pylorus 
is  accurately  bounded  by  the  pyloric  ring,  and  never  extends  to  the 
duodenum  ;  whereas  when  cancer  occurs  at  the  cardia,  excepting,  of 
course,  those  cases  in  which  it  descends  from  the  oesophagus,  it  inva- 
riably involves  a  portion  of  the  latter. 

The  scirrhous  pylorus  is  commonly  bound  down  by  the  degeneration 
of  the  tissues  that  lie  behind  it ;  but  exceptions  occur  which  require  the 
more  to  be  known,  as  they  materially  affect  the  diagnosis.  The  dege- 
nerated pylorus  may  remain  unattached,  and  will  then,  owing  to  its  in- 
crease in  weight,  descend  to  a  lower  region  of  the  abdomen,  even  down 
to  the  symphysis  pubis,  causing  a  hard,  very  movable  tumor,  which  easily 
gives  rise  to  mistakes. 

In  proportion  as  the  parietes  increase  in  size  and  thickness,  the  ste- 
noses of  the  pyloric  channel  will  be  more  or  less  considerable ;  nodose 
protuberances,  uneven  contraction  of  the  tissues,  and  corrugation  of  the 
parietes,  give  rise  to  inflections  presenting  a  more  or  less  acute  angle. 
The  greater  the  stenoses,  and  the  more  the  cancerous  degeneration  is 
limited  to  the  pylorus,  the  more  considerable  will  be  the  dilatation  of 
the  stomach,  which  sometimes  reaches  an  enormous  size,  and  presents  a 
more  or  less  hypertrophied  state  of  its  muscular  coat. 

It  is  very  frequently  found  to  contain  the  well-known  chocolate- 
colored  fluid  resembling  coffee-grounds,  the  origin  of  which  is  apparent 
from  the  various  conditions  of  the  inner  gastric  surface  we  have  above 
examined. 

Cancer  of  the  stomach  in  most  instances  is  uncomplicated,  but  it  is 
also  found  coexistent  with  cancer  of  the  liver,  of  the  lumbar  glands,  of 


46  ABNORMITIES    OF    THE 

the  intestine,  and  especially  of  the  rectum,  of  the  uterus,  the  perito- 
nium,  the  ovary,  &c. 

§  7.  Anomalous  Contents  of  the  Stomach. — Among  the  anomalous 
contents  of  the  stomach,  we  class,  first,  the  secretions  of  the  mucous 
membrane,  which,  both  as  regards  quantity  and  quality,  in  various  ways 
depart  from  their  healthy  condition  ;  secondly,  the  products  of  different 
morbid  processes  which  occur  either  in  the  stomach  or  external  to  it ; 
thirdly,  foreign  bodies  which  have  been  introduced  into  it  from  without 
in  a  variety  of  ways. 

To  the  first  belong  large  collections  of  gas,  of  very  acid  gastric  juice, 
as  we  find  occurring  in  chronic  gastritis  and  many  other  morbid  meta- 
morphoses of  the  gastric  membranes,  the  absence,  but  more  frequently 
the  excess,  of  a  white,  milky,  opaque,  and  purulent,  or  of  a  transparent, 
viscid,  gelatinous,  glassy  mucus,  such  as  we  find  in  chronic  catarrhs,  or 
in  a  blennorrhoic  condition  of  the  gastric  mucous  membrane. 

To  the  second  belong  the  products  of  exudative  processes,  and  of 
ulcers  in  the  stomach  itself,  such  as  plastic,  viscid  mucous,  fibrinous 
exudation,  pus,  ichor.  The  latter  may  also  be  introduced  from  without, 
from  abscesses  of  contiguous  organs,  the  liver,  the  spleen,  the  pancreas, 
the  lymphatic  glands,  from  ulcers  of  the  oesophagus,  and  even  from  ab- 
scesses of  the  vertebrae. 

Blood  occurs  in  varying  quantities ;  when  found  to  a  large  amount 
either  in  a  coagulated  or  fluid  condition,  it  commonly  has  its  source  in 
rupture  of  varicose  veins  of  the  oesophagus  or  stomach,  in  rupture  of  an 
aneurism  communicating  with  those  cavities,  or  in  corrosion  of  arteries 
lying  at  the  base  of  a  perforating  gastric  or  duodenal  ulcer.  Occa- 
sionally, too,  the  capillary  bleedings  which  accompanying  follicular  in- 
flammation and  erosion,  degenerate  into  such  exhausting  hemorrhages. 

Blood  may  also  occur  as  a  reddish-brown,  or  black  pulverulent  sub- 
stance, either  mixed  up  with  the  contents  of  the  stomach,  and  especially 
with  the  mucous  secretion,  in  the  shape  of  streaks  or  flocculi,  or  attached 
to  the  mucous  membrane,  and  more  especially  to  the  bleeding  portions. 

Or  it  may  occur  as  a  chocolate-colored,  cofiee-ground-like  or  inky 
matter,  and  that  will  be  the  case  under  all  circumstances  that  give  rise 
to  gastric  hemorrhage,  if  the  blood  has  been  retained  in  the  stomach  for 
a  certain  period,  and  submitted  to  the  action  of  the  gastric  juice.  It  is 
evident  that  this  will  chiefly  be  the  case  in  passive  hemorrhages.  We 
gather  from  the  preceding  observations  that  the  following  are  the  cases 
in  which  the  contents  of  the  stomach  present  this  appearance,  and  in 
which  there  will  be  vomiting  of  black  matter  during  life : 

a.  In  slow  hemorrhage  from  a  perforating  ulcer  of  the  stomach ; 

b.  In  capillary  hemorrhage  accompanying  hemorrhagic  erosion  of  the 
gastric  mucous  membrane  and  their  follicles ; 

c.  In  softening ; 

d.  In  the  hemorrhages  that  accompany  cancer  of  the  stomach. 

In  rare  cases  we  find  blood  in  the  stomach  without  being  able  to  trace 
a  distinct  cause  of  the  hemorrhage,  either  in  or  out  of  the  organ  ;  the 
parietes  of  the  stomach  are  either  found  to  be  in  a  state  of  complete 
anaemia,  or  occasionally  single,  red,  injected  portions  of  the  mucous 


INTESTINAL    CANAL.  47 

membrane  are  visible,  which  bleed  on  the  application  of  slight  pressure 
from  below,  by  which  the  congestion  is  increased.  There  is  no  doubt 
that,  in  such  cases,  hypersemise  of  various  kinds  precede,  and  blood  at 
once  transudes  through  the  vascular  coats ;  the  greater  the  impulse  of 
the  blood,  the  laxer  the  tissue  and  the  vascular  coats,  and  the  thinner 
the  blood  itself  is,  the  easier  will  this  be  brought  about. 

The  blood  which  is  found  in  the  stomach  is  not  only,  as  we  have  re- 
marked, frequently  the  result  of  extravasation  which  has  taken  place 
external  to  the  stomach,  but  it  may  even  have  been  extravasated  ex- 
ternal to  the  oesophagus  and  intestinal  canal.  Thus  it  is  often  swal- 
lowed in  large  quantities  during  hemorrhages  of  the  respiratory  mucous 
membrane. 

Finally,  there  may  be  bile,  biliary  calculi,  fecal  matter,  and  lumbrici, 
in  the  stomach. 

To  the  third  class  belong  the  most  various  foreign  bodies  which  have 
been  swallowed  accidentally,  or  in  consequence  of  morbid  appetites ;  in 
the  latter  case,  chiefly  seen  in  lunatics,  they  are  taken  in  large  quan- 
tities, and  with  evident  selection.  We  may  enumerate  flints,  clay,  in- 
digestible vegetables,  grass,  and  straw,  waste  pieces  of  clothing ;  metallic 
substances,  as  coins,  bullets,  iron  nails,  pins,  £c.  They  give  rise  to 
various  lesions,  to  perforation  of  the  stomach,  or  at  least,  to  irritation 
and  inflammation,  with  subsequent  ulceration  of  the  mucous  membrane. 

SECT.  Y. — ABNORMITIES   OF  THE  INTESTINAL  CANAL. 

§  1.  Defective  and  excessive  Formation. — A  complete  absence  of  the 
intestinal  canal  when  an  abdominal  cavity  existed,  has  probably  never 
been  observed.  It  is  frequently  defective ;  at  times  it  is  a  short  tube 
of  uniform  calibre,  attached  to  a  flat  narrow  strip  of  mesentery,  or  it 
consists  of  several  detached  portions  of  intestine  which  are  strung  toge- 
ther on  a  very  defective  fold  of  the  peritoneum. 

We  must  here  mention  the  blind  termination  of  the  intestine  at  dif- 
ferent points  of  its  course,  there  being  either  a  fresh  acuminated  com- 
mencement lower  down,  or  an  absence  of  the  remaining  portion.  The 
most  frequent  anomaly  is  the  more  or  less  extensive  deficiency  of  the 
rectum  with  a  consequent  atresia  ani.  The  latter  abnormities  demand 
the  formation  of  an  artificial  anus  at  the  natural  situation,  or  at  some 
other  suitable  part,  if  they  occur  in  individuals  who  are  otherwise  capable 
of  sustaining  life. 

Defective  formation  may  occur  in  the  shape  of  tissue,  of  irregular  com- 
munication of  the  intestinal  tube,  as  in  the  case  of  the  latter  discharging 
at  the  navel,  into  the  cavity  of  the  urinary  or  small  sexual  organs 
(cloaca) ;  it  then  is  commonly  the  result  of  an  arrest  of  development. 

Excess  of  development,  with  the  exception  of  the  various  degrees  of 
biventral  monstrosities,  is  probably  nothing  but  a  deceptive  appearance  ; 
the  repetition  of  some  of  its  segments,  and  the  presence  of  larger  or 
smaller  blind  appendices,  which  open  outwards  or  into  the  intestine,  and 
more  especially  the  so-called  diverticula,  are  almost  invariably  to  be 
considered  as  arrests  of  formation. 

The  latter,  the  congenital  diverticula,  Meckel's  diverticulum  verum, 


48  ABNORMITIES    OF    THE 

deserve  a  special  consideration.  It  is  a  dilatation  of  the  small  intestine, 
representing  a  hollow  appendix,  which  consists  of  all  the  intestinal 
membranes,  and  is  placed  at  from  eighteen  to  twenty-four  inches  from 
the  caecal  valve  ;  although  we  do  not  quite  assent  to  Meckel's  view,  that 
it  is  a  remnant  of  the  umbilical  canal,  it  evidently  has  its  origin  in  the 
development  of  the  intestine  in  the  umbilical  vesicle.  We  accordingly 
always  find  it  solitary  and  attached  at  the  above-mentioned  spot ;  it 
varies  in  length  from  five  to  six  inches ;  it  sometimes  is  wider,  some- 
times narrower,  than  the  intestine  itself ;  it  is  frequently  contracted  at 
intervals,  of  a  conical  or  cylindrical  shape,  and  terminating  in  a  round, 
clubbed,  or  lobulated  expansion.  It  either  projects  at  right  angles  from 
the  convex  surface  of  the  intestine,  hanging  unattached  in  the  abdomen, 
or  it  passes  off  at  an  acute  angle  from  the  concave  surface  of  the  intes- 
tine near  the  mesenteric  insertion,  being  attached  to  the  latter  by  a  falci- 
form process  of  the  peritoneum.  In  this  case  it  is  often  placed  parallel 
to  the  intestine.  Occasionally  a  ligamentous  cord,  the  remains  of  the 
omphalo-meseraic  vessels,  is  found  at  its  free  extremity,  and  as  this  may, 
by  its  adhesion  to  various  points  of  the  peritoneal  cavity,  give  rise  to 
internal  hernia  (strangulation  of  the  intestine),  it  receives  importance  in 
a  pathognomonic  point  of  view. 

The  following  case,  in  which  this  appendix  was  abortive,  may  be  in- 
teresting :  In  the  corpse  of  a  young  man,  the  small  intestine  was  found 
enlarged  at  the  above-mentioned  spot,  to  the  extent  of  several  inches, 
the  peritoneum  and  the  adjoining  laminae  of  the  mesentery  were  white 
and  opaque,  studded  with  tendinous  patches,  and  a  tolerably  long  liga- 
mentous cord,  the  remains  of  the  bloodvessels,  was  found  depending  from 
a  rounded  embossed  dilatation. 

We  may  finally  observe  that  the  entire  intestinal  canal  or  portions  of 
it,  are  found  in  some  individuals  inordinately  long  or  short ;  no  fixed 
rule  has,  however,  been  established  with  regard  to  the  relation  among 
the  parts  themselves,  to  the  stomach,  the  organs  of  mastication,  &c. 

§  2.  Abnormities  of  Size. — The  congenital  malformations  belonging 
to  this  section,  are  the  anomalies  which  we  have  described  above,  when 
speaking  of  the  length  of  the  intestine,  and  the  true  diverticulum. 

The  acquired  malformations,  as  distinguished  from  the  former,  have 
reference  to  the  calibre  of  the  intestine,  and  are  either  dilatations  or 
contractions. 

The  former  occur  either  as  uniform  dilatations  of  the  tube,  or  a  lateral 
extension. 

Uniform  dilatation  is  the  result  of  atony,  or  paralysis,  consequent 
upon  concussion,  habitual  repletion,  peritonitis,  rheumatism,  typhus, 
dysentery,  cholera,  overstimulation  by  injections  and  purgatives,  and  the 
like  ;  or  it  is  the  immediate  consequence  of  disease  in  the  nervous  cen- 
tres ;  or  the  dilatations  may  be  developed  as  dilatations  of  an  active 
character,  i.  e.  with  hypertrophy  of  the  muscular  coat  above  a  constric- 
tion. In  accordance  with  their  etiological  relations,  they  occur  chiefly 
in  the  colon. 

The  lateral  dilatation  of  the  intestine  occurs  in  a  form  resembling  a 
diverticulum,  constituting  the  false,  in  contradistinction  to  the  true  di- 


INTESTINAL    CANAL.  49 

verticulum ;  it  is  a  hernia  of  the  intestinal  mucous  membrane,  resulting 
from  the  separation  of  the  fibres  of  the  muscular  coat.  It  differs  in 
every  one  of  its  characters  from  the  true  diverticulum  : 

1st.  False  diverticula  consist  solely  of  mucous  membrane  and  perito- 
neum ; 

2d.  They  occur  at  the  duodenum,  in  the  entire  course  of  the  small  and 
large  intestines ; 

3d.  They  are  found  in  considerable  numbers ; 

4th.  They  occur  from  the  size  of  a  pea  to  that  of  a  walnut,  in  the 
shape  of  round,  baggy  pouches  of  the  mucous  membrane  ; 

5th.  They  form,  more  especially  in  the  colon,  nipple-shaped  appen- 
dages, which  occasionally  are  grouped  together  in  bunches ;  when  occur- 
ring in  the  small  intestine,  they  are  commonly  developed  on  its  concave 
side,  and  are  therefore  placed  between  the  layers  of  the  peritoneum ; 
when  in  the  colon,  the  faeces  are  retained  by  them,  and  dry  up  into  stony 
concretions. 

Contraction  of  the  calibre  of  the  intestine  at  a  small  portion,  or  in  a 
greater  extent,  is  the  effect  of  the  pressure  or  traction  exerted  by  large 
morbid  growths,  by  hypertrophied  contiguous  organs,  the  impregnated 
uterus,  uterine  fibroid  tumors,  dropsy  or  cancerous  degeneration  of  the 
ovary,  &c. ;  it  is  brought  on  by  incarceration  or  traction  of  the  intestine 
in  external  and  internal  herniae,  by  invagination,  by  adhesion  of  the  in- 
testine, accompanied  by  angular  inflection  at  the  point  of  adhesion  ;  by 
compression  of  a  large  portion  of  intestine  into  a  small  space,  in  conse- 
quence of  a  firm  adhesions  between  the  coats  and  the  peritoneum ;  it  is 
produced  by  disease  of  the  tissues,  and  more  especially  by  cancer  (can- 
cerous stricture),  by  cicatrization  of  tubercular  ulcers,  by  the  healing  of 
loss  of  substance  in  dysentery,  by  catarrhal  suppuration,  by  the  scar  fol- 
lowing a  gangrenous  slough,  or  by  simple  hypertrophy.  The  passage 
of  the  intestine  is  moreover  interfered  with  or  entirely  obstructed,  by 
tumors  which  project  into  the  intestinal  cavity,  and  it  is  variously 
affected  by  foreign  bodies. 

We  have  lastly  to  remark,  that  we  find  various  states  of  contraction 
and  vacuity  of  the  intestine  coexistent  with  its  blind  termination,  with 
an  artificial  anus,  or  with  stricture. 

In  a  different  point  of  view  we  must  here  cite  the  anomalies  which 
occur  in  the  dimensions  of  the  intestinal  parietes  :  they  appear  in  the 
shape  of  augmentation  or  diminution,  i.  e.  thickening  or  thinning. 
Thickening  is  found  to  accompany  or  result  from  textural  diseases,  under 
which  head  this  form  will  be  considered ;  but  it  also  presents  itself  as 
simple  hypertrophy. 

This  either  affects  the  mucous  membrane  and  the  muscular  coat  sepa- 
rately, or  both  simultaneously,  together  with  the  intervening  cellular 
tissue.  In  the  first  and  last  cases  it  is  the  result  of  a  repeated  and 
habitual  state  of  irritation  of  the  intestinal  mucous  membrane,  which,  in 
accordance  with  a  uniform  law,  after  a  certain  duration  gives  rise  to 
hypertrophy  of  the  muscular  coat,  and  an  increase  in  the  density  and 
quantity  of  the  intervening  cellular  layer.  The  hypertrophy  of  the 
mucous  membrane  is  presented  to  us  in  a  very  characteristic  shape  in 
polypus  of  the  intestine  ;  this  growth  is  peculiar  to  the  colon,  and  chiefly 

VOL.  II.  4 


50  ABNORMITIES    OF    THE 

to  its  terminal  portion,  being  often  remarkable  for  its  length,  its  frequent 
repetition,  and  the  massive  cauliflower-like  development  of  its  free  ex- 
tremity. When  hypertrophy  exclusively  or  mainly  affects  the  muscular 
coat,  it  generally  results  from  excessive  innervation  accompanying 
habitual  spasm  of  the  intestine,  or  from  extreme  excitement  of  its  mus- 
cular activity  induced  by  repeated  or  continual  repletion,  as  we  see 
following  a  stricture. 

Excessive  thinning  of  the  intestinal  mucous  membrane,  presenting  an 
appearance  which  resembles  that  of  serous  membranes,  occurs  chiefly  in 
the  colon  after  the  protracted  serous  diarrhoeas  which  accompany  con- 
sumptive diseases ;  the  tissues  are  there  found  in  an  anaemic  and  pallid 
condition,  without  exhibiting  any  conspicuous  anomaly  in  consistency. 

Atrophy  of  the  muscular  and  mucous  coats  of  the  intestine  is  often 
seen  in  connection  with  tabes  universalis,  though  rarely  as  it  appears, 
dependent  upon  idiopathic  torpor  of  the  abdominal  ganglia  ;  it  is  found 
coexistent  with  a  wasting  of  the  mesenteric  glands  in  hypochondriac  and 
melancholic  affections,  or  as  a  signal  of  certain  acute  processes,  as  for 
instance,  of  typhus,  or  as  a  consequence  of  slow  poisoning  by  lead.  The 
thinning  which,  coupled  with  relaxation  and  friability  of  the  intestinal 
membranes,  occasionally  exists  simultaneously  with  an  accumulation  of 
fat  in  the  mesenteries  and  omentum,  is  still  more  remarkable.  The  ex- 
cessive production  of  fecal  matter  (copropoesis  excedens)  which  fre- 
quently accompanies  these  two  conditions,  is  important  in  reference  to 
their  pathogeny. 

The  follicular  apparatus  frequently  becomes  atrophied  at  an  advanced 
age,  but  it  may  be  similarly  affected  in  consequence  of  acute  diseases, 
such  as  ileo-typhus.  Berres  has  demonstrated  senile  atrophy  in  the  in- 
testinal villi. 

§  3.  Deviations  of  Position. — The  intestinal  canal  may  be  irregular 
in  position,  either  being  placed  altogether  external  to  the  abdominal 
cavity,  or  by  its  relations  and  its  disposition  within  the  cavity  being 
irregular. 

In  the  first  class  we  reckon  the  following  congenital  irregularities  : 
protrusion  of  the  intestines,  external  to  the  abdomen,  from  absence  of 
the  parietes,  or  from  fissure  at  or  near  the  median  line  (eventration, 
omphalocele,  congenital  umbilical  hernia) ;  congenital  inguinal  hernia  ; 
thoracic  hernia  from  partial  or  total  absence  of  the  diaphragm,  the  left 
side  of  the  latter  being  chiefly  liable  to  this  malformation.  To  the 
acquired  irregularities  belong  prolapsus  of  the  intestines,  resulting  from 
penetrating  wrounds  of  the  abdomen,  wounds  or  rupture  of  the  diaphragm, 
and  the  different  forms  of  ordinary  hernia. 

In  the  second  class  we  reckon,  as  a  congenital  deviation,  the  lateral 
transposition  which  is  likely  at  the  same  time  to  involve  secondarily,  not 
only  the  other  abdominal,  but  also  the  thoracic  viscera ;  the  various 
changes  of  position,  produced  by  diffused  or  circumscribed  fluid  effusions 
or  accumulations,  by  hypertrophied  viscera,  or  by  morbid  growths  ;  the 
spontaneous  descent  of  the  transverse  colon  into  the  hypogastric  region, 
of  the  small  intestine  into  the  pelvic  cavity ;  external  and  so-called  in- 
ternal hernia ;  invagination  and  prolapsus  ani,  the  two  being  identical  in 


INTESTINAL    CANAL.  51 

character  and  causation ;  the  changes  of  position  which  the  intestine  ex- 
periences in  consequence  of  the  cellular  or  fibro-cellular  adhesions  that 
it  forms  with  the  parietes,  and  that  unite  the  coils  to  one  another. 

For  external  hernia  we  refer  the  reader  to  surgical  works ;  we  shall 
here  examine  only  the  relations  of  internal  hernia,  invagination,  prolap- 
sus ani,  and  the  change  of  position  produced  in  the  intestines  by  adhe- 
sion. 

1.  Internal  hernia.* — We  define  internal  hernia,  in  contradistinction 
to  external  hernia,  as  a  change  of  position  in  the  intestine  leading  to  in- 
carceration, which  occurs  in  the  abdominal  cavity  without  the  formation 
of  a  hernial  sac,  and  which  is  therefore  not  accessible  to  the  usual  mode 
of  examination  applicable  to  external  hernia.  Certain  cases  in  which  the 
intestine  is  placed  or  incarcerated  in  congenital  folds  or  pouches  of  the 
peritoneum,  such  as  we  occasionally  see  in  the  hypogastric  region,  are  to 
be  viewed  as  transition  forms  between  internal  and  external  hernia  (vid. 
Peritoneum,  p.  24).  The  former  are  also  termed  incarceratio,  strangu- 
latio  internet. 

They  may  be  subdivided  in  the  following  manner : 

a.  Incarceration  is  the  result  of  the  simple  pressure,  which  is  exerted 
upon  one  or  more  points  of  the  intestinal  tube,  by  a  portion  of  the  intes- 
tine or  by  the  mesentery,  resting  upon  the  former.      It  is  a  matter  of 
course  that  this  simple  compression  of  a  portion  of  the  intestine,  can  only 
be  effected  in  the  direction  of  the  resisting  posterior  walls  of  the  abdomen, 
and  at  its  lower  segment ;  inasmuch  as  the  occurrence  of  a  similar  rela- 
tion pnteriorly  is  inconceivable,  on  account  of  the  smoothness  and  yielding 
nature  of  the  parts.    Experience  confirms  the  fact  that  the  small  intestine, 
from  repletion  or  increase  of  volume,  is  particularly  prone  to  occupy  ab- 
normal positions ;  it  is  very  liable  to  descend,  and  with  its  lengthy  and 
frequently  hypertrophied  mesentery,  fall  and  weigh  upon  the  colon  or  the 
rectum,  and  to  compress  their  walls. 

These  incarcerations  of  the  intestine  commonly  occur  at  an  advanced 
age,  at  which  a  descent  of  the  intestines  to  a  lower  region  of  the  abdo- 
men and  into  the  pelvic  cavity,  prolapsus  of  the  pelvic  viscera  and  large 
hernise,  which  may  be  viewed  as  analogous  conditions,  are  very  frequent. 

A  long,  flabby  mesentery  predisposes  to  the  complaint;  especially 
when,  by  traction,  it  has  been  converted  into  a  pedicle  or  cord.  Reple- 
tion of  the  intestine  above  a  stricture,  accompanied  by  atony,  or  the 
dislocation  of  the  intestine  in  large  hernias  (inguinal  and  scrotal  hernise), 
is  likely  to  produce  this  effect. 

b.  Incarceration  may  be  the  consequence  of  a  rotatory  movement,  and 
of  this  there  are  three  varieties : 

«.  A  portion  of  intestine  may  have  become  twisted  upon  its  own  axis, 
and  we  then  find  that  even  semi-rotation  causes  such  an  approximation 
of  its  parietes,  that  they  touch  and  close  up  the  passage.  This  can  pro- 
bably only  occur  in  the  colon,  and  according  to  the  cases  on  record,  only 
in  the  colon  ascendens.  Accumulations  of  gas,  and  unequal  filling  of 
different  portions  of  the  intestine,  appear,  as  far  as  we  are  able  to  judge 
from  the  few  cases  which  have  been  noticed,  to  be  the  cause.  Such  an 

1  Vide  Oestr.  Jahrb.  x.  4. 


52  ABNORMITIES    OF    THE 

occurrence  is  scarcely  conceivable  in  the  small  intestine,  on  account  of 
the  uniformity  of  its  calibre,  the  absence  of  angular  flexures,  and  its  loose 
position,  as  every  rotation  of  one  portion  upon  its  axis  would  be  counter- 
balanced by  the  rotation  of  the  next  segment. 

/9.  The  mesentery  may  be  the  axis,  and  the  intestine  will  then  be  rolled 
up  upon  the  former,  i.  e.,  the  entire  mesentery,  or  a  portion  of  it,  is 
twisted  into  a  cone,  and  in  proportion  to  the  number  of  its  rotations, 
more  or  less  of  the  intestine  will  be  dragged  after  it.  In  this  case  we 
must  take  into  consideration  the  traction  and  the  pressure,  which  the  in- 
testine suffers  at  the  acute  angle,  which  the  dependent  mesenteric  cone 
forms  with  the  base  whence  its  point  rises.  This  variety  can  scarcely 
occur  anywhere  but  in  the  small  intestine  and  its  mesentery. 

Y.  One  portion  of  the  intestine,  either  single  or  double — a  coil — may 
afford  the  axis  round  which  another  portion  with  its  mesentery  is  thrown, 
so  as  to  be  throughout  in  contact  with  the  circumference  of  the  axis,  and 
thus  to  compress  it  like  a  ferrule.  This  variety  is  evidently  a  higher 
degree  of  the  first  in  which  a  portion  of  intestine  is  merely  compressed 
from  before  backwards,  and,  as  it  were,  flattened  down.  A  coil  of  small 
intestine,  the  sigmoid  flexure,  or  the  caecum,  may  form  the  axis. 

The  last  two  varieties  occur  like  the  first,  chiefly  at  an  advanced  period 
of  life.  In  early  life  a  predisposition  to  the  affection  may  be  caused  by 
a  congenital  malformation  of  the  mesentery,  by  large  hernise,  or  by  small 
hernias  when  there  is  adhesion  of  the  intestine. 

This  predisposition  consists,  first,  as  in  the  incarcerations  of  the  first 
variety — in  a  congenital  or  acquired  long,  loose,  and  flabby  mesentery, 
by  which  a  rotation  of  the  intestine  round  the  mesentery  or  another  por- 
tion of  intestine  is  rendered  possible ;  and  secondly,  in  an  enlargement 
'of  the  abdominal,  and  especially  of  the  pelvic,  cavity. 

c.  The  incarceration  of  the  intestine  may  be  effected  by  peculiar  struc- 
tures, which  either  belong  to  the  normal  condition,  or  are   congenital 
malformations,  or  are,  in  part  at  least,  the  products  of  previous  morbid 
processes.     We  allude  to  genuine  incarcerations  of  the  intestine  in  vari- 
ous annular  spaces  or  fissures,  of  which  we  cite  the  following : 

a.  The  fissure  of  Winslow,  in  which  we  once  found  a  large  portion  of 
small  intestine  strangulated ; 

ft.  An  intestinal  diverticulum  (verum),  which  is  directly  or  indirectly, 
by  means  of  an  obsolete  vascular  cord,  attached  to  a  certain  portion  of 
the  peritoneum ; 

7.  Adhesions  of  the  free  end  of  the  caecum,  or  of  the  vermiform  pro- 
cess; 

d.  Holes  or  fissures  (congenital  or  acquired)  in  the  mesentery  ; 

e.  Malformations  of  the  omentum,  forming  rounded  or  flattened  cords 
and  bands  which  are  attached  to  the  peritoneum,  or  furcated  fissures  of 
the  omentum ; 

C.  Pseudo-membranous  formations,  as  the  result  of  previous  exudative 
processes,  in  the  shape  of  cellular  or  ligamentous  cords,  bands,  or  plates, 
which  pass  from  one  part  of  the  intestine  or  the  mesentery  to  another, 
from  the  intestine  to  the  abdominal  parietes,  the  omentum  or  an  organ 
of  the  abdominal  and  pelvic  cavity,  or  from  one  of  these  to  the  abdominal 
parietes,  or  between  the  organs  themselves. 


INTESTINAL    CANAL.  53 

It  is  most  frequently  a  portion  of  the  small  intestine  which  is  incar- 
cerated in  these  structures  ;  only  the  more  movable  portions  of  the  colon, 
the  caecum  and  the  sigmoid  flexure,  are  likely  to  become  involved. 

These  varieties  of  incarceration  are  very  common,  and,  as  compared 
with  the  others,  the  most  frequent. 

They  occur  at  every  period  of  life.  The  female  sex  is  more  prone  to 
them  than  the  male,  as  the  omentum,  the  diverticula  that  may  be  present, 
and  pseudo-membranous  formations,  are  not  only  frequently  attached  to 
the  internal  sexual  organs  of  the  female,  but  the  latter  are  themselves 
liable  to  give  rise  to  new  growths. 

The  consequence  of  internal  hernia  is  a  distension  of  the  intestine  above 
the  compressed  or  strangulated  portion,  peritoneal  inflammation,  para- 
lysis, and  ileus ;  the  incarcerated  portion  in  hernia  of  the  third  variety 
is  from  the  strangulation  of  its  mesenteric  vessels  peculiarly  liable  to  con- 
gestion and  gangrene. 

This  affection,  when  diagnosed,  most  imperatively  requires  an  opera- 
tive proceeding,  for  the  purpose  of  disentangling  and  arranging  the  in- 
testines, and  for  division  of  the  strangulating  structures  with  or  without 
the  knife. 

2.  Imagination  of  the  Intestine. — Invagination  or  intussusception,1 
incorrectly  termed  volvulus,  consists  in  the  inversion  of  a  portion  of  in- 
testine into  the  cavity  of  the  adjoining  upper  or  lower  portion. 

We  frequently  find  intussusception  in  the  corpses  of  children  and 
adults,  but  in  the  majority  of  these  cases  it  is  produced  during  the  last 
moments  of  life,  during  the  death-struggle.  It  is  the  result  of  an  unequal 
irritability  of  the  intestine,  and  the  consequent  irregularity  of  its  move- 
ments, and  it  is  therefore  frequent  in  diseases  characterized  by  torpor  of 
the  cerebro-spinal  system,  and  in  the  mortal  agony  proceeding  from  them  ; 
whereas  it  rarely  or  never  occurs  in  diseases  accompanied  by,  or  ending 
with,  abdominal  paralysis  such  as  cholera,  typhus,  general  peritonitis,  &c. 
In  this  case  we  find  no  traces  of  reaction,  the  parts  are  easily  restored  to 
their  proper  relations,  the  inversions  are  found  occurring  simultaneously 
at  several  points,  though  only  in  the  small  intestine,  and  the  inversion 
may  take  place  downwards,  and  at  the  same  time,  but  rarely,  upwards. 

Another  form  of  invagination,  which,  once  formed,  presents  itself  as 
an  idiopathic,  dangerous,  and  often  fatal  disease  of  the  intestinal  tube, 
is  of  extreme  importance,  and  will  be  the  subject  of  the  following 
remarks. 

Every  intussusception  consists  of  three  layers  of  intestine :  of  these, 
reckoning  from  without  inwards,  the  first  and  second  present  their 
mucous,  the  second  and  third  their  peritoneal,  surfaces  to  one  another. 
The  canal  of  the  intussusception  or  volvulus  passes  through  the  latter. 
In  order  to  facilitate  comprehension,  and  in  accordance  with  fact,  we 
term  the  external  layer  of  the  intestine  the  sheath  of  the  volvulus,  or 
the  intussuscipient  portion,  the  innermost  layer  the  entering  tube,  the 
middle  one  the  receding  or  inverted  tube,  and  the  last  two  together, 
the  intussuscepted  portion,  or  the  volvulus  properly  so-called.  It  follows 
that  isonomic  layers  are  always  opposed  to  one  another ;  and  we  shall 

1  Oestr.  Jahrb.  xiv.  4. 


54  ABNORMITIES    OF    THE 

find  this  to  be  the  case  even  when  the  intussusception  is  double,  and 
consists  of  five  superimposed  layers. 

Between  the  entering  and  inverted  tube  we  find  a  portion  of  mesen- 
tery, of  corresponding  size,  and  of  an  arcuate  form.  It  is  folded  up 
so  as  to  represent  a  cone,  the  apex  of  which  lies  at  the  free  termination 
of  the  volvulus,  with  its  base  in  the  sheath,  and  at  the  entrance  to  the 
invagination. 

This  portion  of  mesentery  is  always  in  a  state  of  tension,  which 
chiefly  affects  the  part  belonging  to  the  inverted  tube,  and  has  a  sin- 
gular influence  upon  the  form  of  the  volvulus.  It  is  the  cause  of  the 
following  circumstances : 

Firstly ;  that  the  volvulus  does  not  lie  parallel  to  its  sheath  but  always 
offers  a  greater  curvature  than  the  latter,  the  inverted  tube  being  com- 
pressed in  its  concavity  into  tense  transverse  folds. 

Secondly ;  that  the  orifice  of  the  volvulus  does  not  lie  in  the  axis  or 
in  the  centre  of  the  sheath,  but  external  to  it ;  and  that,  following  the 
traction  exerted  upon  it  by  the  mesenteric  fold  that  belongs  to  the 
inverted  intestine,  it  is  directed  towards  the  mesenteric  wall  of  the 
sheath ;  that  it  is  not  circular,  but  represents  a  fissure.  This  affords  a 
diagnostic  sign  for  the  examination  of  intussusceptions  of  the  rectum, 
which  are  within  the  reach  of  manual  exploration. 

Intussusceptions  occur  with  equal  frequency  in  the  colon  and  small 
intestine ;  but  several  cases  which  have  been  described  as  occurring  in 
the  former  are  remarkable  on  account  of  the  magnitude  they  attained. 
In  these  cases  the  sheath  contains  a  very  long  portion  of  the  colon  and 
ileum  ;  both  may  be  inverted  two  or  three  times,  and  the  intussuscepted 
part  advances  to  the  vicinity  of  the  anus. 

An  inversion  of  the  intestine  from  above  downwards  is  the  most 
usual  occurrence.  Post-mortem  examinations  have,  with  very  rare 
exceptions,  proved  this  to  be  the  case ;  and  it  is  but  fair  to  assume  the 
same  in  those  cases  in  which,  after  urgent  symptoms  of  danger,  larger 
or  smaller  portions  of  intestine  were  discharged,  and  the  patients  reco- 
vered. 

We  naturally  ask  how  the  intussusception  is  brought  about,  and  how 
its  enlargement  is  effected  ? 

The  cause  is  to  be  found  either  in  the  contraction  and  movability  of 
a  piece  of  the  intestine,  on  which  account  it  passes  into  the  adjoining 
and  more  capacious  tube ;  or  in  the  extreme  expansion  or  relaxation  of 
a  segment  of  intestine,  which  gives  rise  to  an  inversion  of  the  adjoining 
narrower  and  more  innervated  portion.  In  every  case  the  volvulus  is 
formed  at  the  expense  of  the  external  layer  of  the  intestine  or  sheath. 
For  we  find  that  the  entering  portion,  as  it  enters  and  advances  (in- 
crease of  the  volvulus),  is  not  reverted  at  its  free  termination  to  form 
the  receding  tube,  but  that  the  latter  is  formed  by  the  inversion  of  the 
sheath  at  the  entrance  of  the  volvulus.1 

Whether  the  intussusception  takes  place  in  one  way  or  the  other,  the 
volvulus  is  not  immediately  subjected,  as  is  commonly  thought,  to  an- 

1  [In  other  words,  the  volvulus  increases  at  the  expense  of  the  inferior  portion  of  the 
intestine. — ED.] 


INTESTINAL    CANAL.  55 

nular  strangulation.  In  the  first  instance,  the  mesentery  of  the  volvulus 
and  its  vessels  suffer  tension  and  compression  at  their  entrance  into  the 
sheath ;  and,  in  consequence,  we  have  in  the  volvulus  an  obstruction  to 
the  circulation,  with  swelling  and  intense  redness,  in  short,  violent 
inflammation,  which  gives  rise  to  sero-sanguineous  infiltration  of  the 
tissues,  plastic  effusion  on  the  contiguous  serous  surfaces  of  the  entering 
and  receding  tuhe,  and  upon  the  mucous  membrane  of  the  latter.  The 
inverted  portion  is  invariably  the  one  that  suffers  most ;  the  inflamma- 
tion of  the  entering  tube  is  less  considerable,  and  it  is  characteristic, 
that  even  when  the  inflammation  of  the  volvulus  runs  high,  its  mucous 
membrane  remains  pale ;  the  sheath  of  the  volvulus  also  is  but  slightly 
affected  in  small  intussusceptions,  with  the  exception  of  the  peritonitis 
at  the  point  where  it  enters.  In  large  invaginations  of  the  intestine, 
however,  the  sheath  is  more  deeply  involved  in  the  inflammatory  affec- 
tion on  account  of  the  tension  of  the  mesentery  and  the  strangulation  of 
the  vessels. 

In  consequence  of  the  tumefaction  that  results  from  the  inflammation 
of  the  volvulus,  we  find,  as  a  secondary  occurrence,  the  formation  of  a 
true  annular  incarceration,  either  at  the  entrance,  or  in  rare  cases,  at 
other  points. 

During  this  period,  in  which  the  volvulus  becomes  fixed,  in  conse- 
quence of  the  tumefaction,  the  incarceration,  and  even  the  adhesion  of 
the  contiguous  serous  surfaces,  which  is  brought  about  by  plastic  exuda- 
tion, it  gradually  or  periodically  enlarges  to  an  enormous  extent ;  the 
peristaltic  action,  and  the  increased  accumulation  of  the  intestinal  con- 
tents, forcing  the  volvulus,  the  sheath  of  which  continues  to  be  progres- 
sively inverted,  lower  down.  We  are  thus  led  to  distinguish  between  a 
primary  and  a  consecutive  form. 

If  the  intussusception  does  not  prove  fatal  by  the  peritonitis  which 
extends  upwards  from  the  serous  surfaces  of  the  entering  and  receding 
tube,  with  symptoms  of  strangulation,  or  by  gangrene  of  the  volvulus, 
it  may  have  other  more  or  less  favorable  terminations. 

a.  The  most  favorable  issue,  although  purchased  at  the  greatest  risk 
of  life,  is  gangrene   and  discharge  of  the  volvulus  and  its  mesenteric 
portion,  subsequent  to  a  complete  adhesion  between  the  entering  and 
receding  tube  at  the  entrance  into  the  sheath.     At  the  spot  where  the 
separation  has  taken  place,  we  find,  in  the  corpses  of  individuals  who 
had  been  thus  affected,  an  annular  swelling,  which  more  or  less  inter- 
feres with  the  calibre  of  the  intestine,  and  adhesions  with  the  contiguous 
peritoneal  surface,  and  more  particularly  of  the  mesentery. 

b.  In  rare  cases,  in  which  the  incarceration  has  been  developed  at  an 
unusual  point,  only  a  partial  sloughing  of  the  volvulus  takes  place,  and 
the  portion  which  lies  above  the  strangulation  is  retained.     Under  these 
circumstances,  the  latter  forms  a  conical  plug  with  a  narrow  channel, 
and  projects  into  the  cavity  of  its  sheath,  surrounded  by  a  thick  fringe 
of  mucous  membrane. 

c.  Occasionally  the  inflammatory  action  which  has  taken  place  in  the 
volvulus  abates,  after  having  caused  adhesion  between  the  entering  and 
receding  tube,  and  the  volvulus  is  retained. 

The  process  described  under  #,  generally  leaves  a  sufficient  passage, 


56  ABNORMITIES    OF    THE 

and  consequently  ends  in  a  permanent  cure,  which  cannot  be  predicated 
of  the  other  two  events.  In  the  latter,  a  chronic  state  of  hyperaemia 
and  inflammatory  intumescence  remain,  with  a  liability  to  exacerbations. 
General  intestinal  inflammation  not  unfrequently  follows.  The  channel 
of  the  intestine  does  not  suffice  for  the  removal  of  its  contents,  and  the 
volvulus,  or  the  remainder  of  the  volvulus,  are  moreover  the  cause  of  a 
consecutive  increase  of  the  intussusception. 

Invaginations  occur  at  all  ages.  Diarrhoea  is  the  chief  predisposing 
cause,  and  the  most  rational  therapeutic  proceeding  consists,  according 
as  the  inversion  has  taken  place  upwards  or  downwards,  in  an  early 
injection  or  exhaustion  of  air  by  means  of  a  syringe.  To  be  effective, 
this  must  be  done  before  the  volvulus  has  formed  adhesions. 

Intussusception  has  an  analogue  in  prolapsus  ani. 

3.  Prolapsus  ani. — Prolapsus  ani  is  a  volvulus  without  a  sheath,  and 
it  is  characterized  by  an  inversion  of  the  internal  portion  of  the  intes- 
tinal tubing.     It  represents  a  sausage-shaped  or  pyriform  tumor,  which 
is  contracted  at  the  anus,  so  as  to  form  a  pedicle,  and  at  the  free  extre- 
mity there  is,  in  trifling  cases,  a  round  central  opening,  which  in  larger 
prolapsus  assumes  an  eccentric   position,   and,   following  the  traction 
exerted  upon  it  by  the  mesorectum,  recedes  so  as  to  present  a  mere 
fissure.      The  external  mucous  layer  is  the  seat  of  inflammation  and 
swelling,  which  partly  proceeds  from  mechanical  hypersemia,  partly  from 
irritation  produced  by  the  atmosphere.     It  is  the  result  of  violent  and 
lasting  diarrhoea  in  children,  or  of  blenhorrhoea  of  the  rectum  in  adults 
and  old  people. 

4.  Altered  position  of  the  intestine  consequent  upon  adhesions. — These 
changes  of  position1  vary  according  to  the  point  of  adhesion,  and  assume 
very  different  forms.     They  are  of  importance,  as  they  sometimes  offer 
impediments  to  the  propulsion  of  the  contents  of  the  intestine ;  but  this 
is  not  in  a  ratio  with  the  extent  or  degree  of  adhesion,  but  bears  a  direct 
relation  to  the  degree  of  dislocation  produced  in  one  or  more  coils  of 
intestine.     We  are  now  alluding  to  the  adhesions  produced  by  cellular 
or  fibro-cellular  tissue,  the  remains  of  an  entirely  extinct  exudative  pro- 
cess, since  we  find  that  similar  adhesions,  when  accompanied  by  hetero- 
logous  formations,  and  especially  by  peritoneal  tuberculosis,  rarely  pro- 
duce constipation,  but  almost  invariably  give  rise  to  diarrhoea. 

We  therefore  speak  of  the  following  forms : 

a.  Partial  circumscribed  adhesions  of  the  intestine,  with  the  abdominal 
parietes,  with  a  second,  less  movable  portion  of  the  tube,  with  the  me- 
sentery, with  the  internal  female  sexual  organs,  &c.,  causing  an  angular 
inflection  of  the  intestine.     The  inflection  will  be  the  more  considerable, 
the  more  the  adhesion  is  limited,  and  the  more  remote  the  latter  is  from 
the  normal  position  of  the  intestine. 

When  occurring  at  the  colon,  the  dislocation  may  be  induced  by  direct 
adhesions  of  the  less  attached  portions,  or  indirectly  by  the  adhesions  of 
the  omentum,  especially  when  the  latter  is  shortened,  or  when  it  lies  in 
the  sac  of  an  inguinal  or  femoral  hernia. 

b.  Extensive  adhesions  among  the  coils  or  the  mesenteries,  that  often 
affect  the  entire  small  intestine,  in  such  a  manner  as  to  twist  and  bend 

1  Oestr.  Jahrb.  xviii.  1. 


INTESTINAL    CANAL.  57 

them,  and  to  produce  external  valvular  duplicatures  of  the  intestinal 
coats  at  the  projecting  angles.  This  form  of  adhesion  is  not  unfre- 
quently  developed  in  intestinal  segments  which  have  long  been  included 
in  large  hernial  sacs,  in  which  case  it  is  limited  in  extent.  A  remarkable 
instance  of  this  was  offered  in  a  case  of  fatal  constipation,  where  a  por- 
tion of  the  ileum,  twenty-four  inches  in  length,  was  found  inclosed  in  a 
cartilaginous  sheath  of  peritoneum  of  four  inches. 

§  4.  Solutions  of  Continuity. — These  are  the  effect  of  penetrating 
injuries  produced  by  cutting  instruments  or  firearms,  or  they  may  be  the 
result  of  concussions  affecting  the  entire  trunk,  as  in  the  case  of  a  fall 
from  a  considerable  height,  or  a  small  portion  of  the  abdomen  only,  as 
from  compression,  in  being  driven  over,  &c.,  in  either  instance  giving 
rise  to  rupture  or  laceration  of  the  intestine ;  or  they  may  be  the  conse- 
quence of  ulcerative  processes  that  proceed  from  without  inwards,  or  vice 
versd,  in  the  shape  of  perforating  intestinal  ulcer. 

The  danger  of  these  lesions  bears  a  direct  relation  to  their  extent,  and 
in  the  last  case,  also  to  the  rapidity  with  which  the  morbid  state  is 
developed. 

We  must  finally  adduce  those  perforations  of  the  intestine  which  are 
the  combined  result  of  mechanical  injury,  and  of  an  ulcerative  process 
brought  on  by  foreign  bodies  that  have  been  introduced  into  the  canal ; 
the  putrefaction  of  the  intestine,  in  consequence  of  sloughing  gangrene 
at  or  near  the  spot ;  and  the  spontaneous  and  incurable  ruptures  of  the 
intestine  which  follow  its  excessive  distension  above  a  stricture,  and  are 
commonly  accompanied  by  circumscribed  sloughing  of  the  mucous  mem- 
brane, or  which  are  the  consequence  of  complete  softening  of  the  coats. 

Unless  the  injury  affects  the  coats  of  the  intestine  in  a  very  slanting 
direction,  we  find  that  in  wounds  produced  by  cutting  or  stabbing,  slough- 
ing or  ulceration,  the  mucous  membrane  projects  over  the  peritoneal  sur- 
face in  the  shape  of  a  tumid  fold.  In  the  case  of  ulcerative  perforation, 
this  will  not  take  place  until  the  destruction  of  the  external  and  internal 
plates  coincide. 

In  those  cases  in  which  a  fatal  termination  is  not  induced  by  an  escape 
of  fecal  matter  into  the  abdominal  cavity,  giving  rise  to  general  perito- 
nitis, nature  adopts  the  following  process  : 

After  a  mechanical  injury  has  been  inflicted,  we  find  that  in  the  vici- 
nity of  the  orifice,  plastic  exudation  immediately  agglutinates  the  perfo- 
rated coil  to  an  adjoining  surface,  which  temporarily  closes  up  the  hole ; 
in  ulcerative  processes  the  perforation  is  generally  anticipated  by  the 
inflammatory  action  of  the  peritoneum  throwing  out  a  guard  of  lymph. 

This  agglutination,  when  following  injuries  to  the  intestines  that  occupy 
the  umbilical  region,  rarely  unites  them  with  the  abdominal  parietes,  ex- 
cept by  the  intervention  of  the  omentum,  which  protrudes  into  the  open- 
ing of  the  abdominal  walls ;  it  commonly  unites  them  to  a  neighboring 
coil.  The  small  intestine  that  lies  in  the  inguinal  region,  the  colon,  a 
portion  of  intestine  included  in  a  hernial  sac,  are  in  close  proximity  to 
parietal  regions  allowing  agglutination,  and  we  there  find  the  lymph 
converted  into  cellular  tissue. 

The  opening  in  the  intestine  communicates  with  the  external  surface 


58  ABNORMITIES    OF    THE 

of  the  body  by  means  of  the  agglutinating  medium.  After  ulcerative  or 
gangrenous  perforation  has  occurred,  the  extravasated  intestinal  contents 
give  rise  to  and  maintain  inflammation  and  ulceration  ;  and  thus  per- 
foration of  the  abdominal  parietes  or  of  the  adjoining  intestinal  coil  is 
induced.  In  the  first  two  cases  an  abnormal  opening  of  the  intestine  out- 
wards is  formed,  which,  according  to  its  size,  and  in  proportion  as  it  suffices 
for  the  discharge  of  feculent  matter,  receives  the  name  of  fistula  sterco- 
ralis  or  anus  artificialis.  In  the  latter  case  an  abnormal  communication 
is  established  between  two  portions  of  intestine  (fistula  bimucosa),  and 
then  we  have  a  condition  which  presents  a  variety  of  complications. 

These  results  may  not  take  place  ;  the  minute  intestinal  orifice  which 
results  from  ulcerative  or  gangrenous  perforations,  not  sufficing  to  induce 
the  secondary  destruction  of  the  adjoining  abdominal  or  intestinal  pa- 
rietes, the  agglutinating  tissue  is  converted  into  a  rounded  extended  cord, 
into  which  the  perforated  intestine  sends  a  funnel-shaped  prolongation  of 
its  mucous  membrane,  and  the  intestine  itself  is  thus  less  firmly  attached. 
Continued  traction  gradually  closes  up  this  funnel-shaped  cavity,  the  cord 
becomes  solid,  and  the  mucous  membrane  cicatrizes  over  it,  generally 
leaving  a  pouch  at  the  spot.  At  a  later  period  the  cord  may  become 
detached,  and  it  then  shrivels  up  into  a  cellulo-fibrous  nodule  lying  above 
the  cicatrix  of  the  mucous  membrane. 

The  cure  of  fistula  stercoralis  is  established  in  a  similar  manner.  The 
intestinal  opening  communicates  by  means  of  a  layer  of  organized  lymph, 
with  the  external  surface  of  the  abdomen.  The  exudation  gradually  be- 
comes distended  so  as  to  form  a  hollow  cord,  which,  to  a  certain  extent, 
is  lined  by  the  mucous  membrane  of  the  perforated  intestine ;  continued 
traction  lengthens  out  the  cord,  its  channel  diminishes  at  the  same  time 
and  finally  closes.  The  immediate  consequence  is  the  healing  up  of  the 
external  fistulous  opening,  and  in  the  same  manner  cicatrization  of  the 
intestinal  orifice  may  be  effected. 

§  5.  Diseases  of  the  Tissues. — The  muscular  coat  is  scarcely  ever 
proved  (by  cadaveric  examination),  to  be  primarily  affected ;  the  disease 
almost  invariably  arises  in  the  mucous  and  the  submucous  cellular  tissue, 
and  involves  the  former  secondarily ;  we  are,  therefore,  the  more  limited 
to  a  consideration  of  the  affections  of  the  mucous  and  the  submucous  cel- 
lular tissues,  as  they  demand  a  minute  investigation  on  account  of  their 
extreme  importance. 

We  may  infer  the  general  importance  of  this  branch  of  pathology  from 
the  rank  the  mucous  membrane  occupies  in  the  domestic  economy,  from 
the  consequent  frequency,  and  the  variety  in  the  forms  of  its  idiopathic 
affections,  but  more  especially  from  the  frequency  of  the  secondary  com- 
plications to  which  it  is  subject,  from  the  numerous  relations  which  it 
bears  to  other  systems  and  organs,  and  the  fluids  at  large. 

We  introduce  the  subject  of  inflammation  by  a  preliminary  considera- 
tion of  the  hypersemic  and  anaemic  states  of  the  mucous  membrane. 

1.  Hypercemia,  Ancemia. — a.  Hypersemia  is  the  result  of  active  con- 
gestion, arising  from  idiopathic,  sympathetic,  or  metastatic  irritation,  or 
it  presents  itself  in  the  passive  form  as  the  precursor  of  asthenic  inflam- 
mation, in  consequence  of  a  paralyzed  state  of  organic  innervation ;  or  it 


INTESTINAL    CANAL.  59 

may  be  purely  mechanical,  arising  from  obstruction  to  the  circulation  by 
pressure,  incarceration  of  the  intestine  and  its  mesentery,  contraction  of 
the  large  vessels  and  the  heart,  impermeability  of  the  lungs,  &c.,  in  which 
case  it  affects  the  veins  chiefly.  In  consequence  of  the  vascular  injec- 
tion, the  mucous  membrane  of  the  intestine  offers  various  degrees  of  red- 
ness, or  there  are  slight  extravasations  or  ecchymoses ;  or,  as  is  particu- 
larly seen  in  the  last  two  cases  of  hypersemia,  the  mucous  membrane,  or 
even  the  entire  membranes  of  the  intestine,  may  present  a  uniform  red- 
dish-black color,  the  tissue  being  saturated  with  blood,  and  no  injection 
of  bloodvessels  being  distinguishable  ;  the  larger  vessels,  and  particularly 
the  venous  trunks  are  distended  even  as  far  as  the  mesenteries,  and  over- 
charged with  blood  (apoplexia  intestini).  In  either  case  hemorrhage 
may  take  place  into  the  cavity  of  the  intestine. 

6.  Anaemia  of  the  intestinal  mucous  membrane  occurs  in  connection 
with  an  atrophic  state  of  the  intestinal  coats,  and  accompanying  tabes 
universalis  and  general  anaemia.  It  is  often  seen  as  a  sequel  of  a  rapid 
consumption  of  the  vital  fluids  from  excessive  diarrhoea  and  exhausting 
discharges,  and  it  appears  in  a  very  marked  form  in  the  gelatinous  soft- 
ening of  the  stomach  and  of  the  intestine  in  children.  The  intestine 
presents  the  color  of  tissue  that  has  been  rendered  pale  by  maceration ; 
or  it  may  have  the  peculiar  yellowish  pallor  of  wax. 

2.  Inflammations  of  the  intestinal  mucous  membrane. — We  are 
acquainted  with  a  catarrhal  (erythematous)  and  a  croupy  form  of  inflam- 
mation, and,  on  account  of  the  prevalence  of  a  dyscrasic  type,  we  may 
consider  the  typhous  and  the  dysenteric  processes  occurring  in  the  intes- 
tinal mucous  membrane  as  allied  to  the  latter. 

a.  Catarrhal  inflammation — or  in  a  lower  degree  mere  catarrhal 
irritation,  catarrh — presents  itself  as  genuine  entero-catarrhus,  with  a 
discharge  of  a  thin  muco-serous  secretion  in  catarrhal  diarrhoeas,  namely, 
as  a  consequence  of  suppressed  cutaneous  exhalation.  It  may  result 
from  mechanical  or  chemical  irritation  of  the  intestinal  mucous  membrane 
by  foreign  bodies  or  stagnating  fecal  matter ;  it  may  also  be  developed 
in  consequence  of  congestive  or  venous  stasis  in  the  portal  system ;  or, 
lastly,  it  frequently  shows  a  specific,  contagious  property  (exanthematic, 
typhoid  catarrhs),  and  appears  as  a  precursor  of  these  processes  or  asso- 
ciated with  them,  and  in  the  vicinity  of  morbid  growths. 

Catarrh  is  either  acute  or  chronic,  and  it  either  attacks  the  mucous 
membrane  uniformly,  or  is  developed  mainly  in  the  villi  and  follicles. 

The  anatomical  signs  of  the  acute  form  are,  more  or  less  intense  red- 
ness and  injection  of  the  mucous  membrane,  affecting  its  entire  surface, 
or  appearing  as  punctiform  reddening  from  affection  of  the  villi,  or  as  a 
vascular  halo  surrounding  the  follicles ;  relaxation  of  the  tissue,  and  in- 
tumescence of  the  mucous  membrane,  equally  affecting  the  entire  substance, 
or  only  the  villi  and  the  follicles,  opacity  of  the  mucous  membrane  and 
its  epithelium  from  infiltration  of  the  former,  and  softening  of  the  latter ; 
friability  and  softening  of  the  mucous  membrane.  The  submucous  cel- 
lular tissue  is  injected,  relaxed,  and  infiltrated  with  a  watery,  opaque 
fluid ;  the  secretion  is  at  first  copious  and  serous  ;  as  the  affection  increases 
in  intensity,  the  former  diminishes  in  amount,  becomes  opaque,  viscid, 
and  puriform. 


60  ABNORMITIES    OF    THE 

Chronic  inflammation  is  characterized,  in  addition  to  the  above  signs, 
by  a  dark,  rusty,  livid  discoloration,  which  in  severe  cases  appears  to 
pervade  the  entire  mucous  membrane ;  by  a  tumid  state  of  the  mucous 
membrane  and  its  follicles,  accompanied  by  increased  density  of  the 
tissue,  copious  secretion  of  an  opaque,  grayish-white,  or  yellow  puriform 
mucus. 

Acute  inflammation  frequently  passes  into  resolution,  but  it  often 
recurs,  and  may,  if  the  predisposing  cause  is  not  got  rid  of,  become 
habitual  or  chronic.  Chronic  inflammation  rarely  admits  of  a  complete 
cure.  It  is  generally  followed  by  a  blennorrhoic  condition  ;  and  we  thus 
find,  in  well-marked  cases,  a  permanent  dilatation  of  the  vessels  esta- 
blished, with  the  following  alteration  in  the  tissues : 

A  brown,  slate-colored,  or  bluish-black  discoloration  of  the  mucous 
membrane  (deposit  of  pigment,)  involving  its  entire  thickness,  or  the  villi 
or  the  follicles  only ; 

Increase  of  substance,  or  permanent  tumefaction  of  the  mucous  mem- 
brane, its  follicles,  or  villi,  with  increased  density  and  consistence  (hyper- 
trophy), giving  rise  in  higher  degrees  to  elongation  of  the  membrane, 
and  formation  of  folds  and  polypi ; 

Hypertrophy  of  the  submucous  cellular  tissue  and  the  muscular  coat ; 

Profuse  secretion  of  a  grayish-white  and  milky,  or  of  a  transparent 
gelatinous  and  viscid  mucus  (pituita  vitrea). 

Catarrhal  inflammation  occasionally  passes  into  suppuration  and  ul- 
ceration.  This  is  found  to  occur  in  consequence  of  frequent  relapses  of 
acute  inflammation,  but  more  particularly  when  an  acute  attack  supervenes 
upon  an  existing  chronic  affection,  or  invades  a  blennorrhoic  mucous 
membrane.  The  mucous  membrane  is  converted  into  a  dark-red,  granu- 
lated and  friable  tissue,  on  the  surface  of  and  within  which  suppuration 
is  established.  This  penetrates  to  the  deeper  tissues,  and  thus  gives  rise 
to  abscesses,  which  open  internally ;  in  either  case  loss  of  substance  is 
entailed,  which  increases  with  more  or  less  rapidity ;  ulcers  follow,  which 
are  surrounded  by  tumid,  irregular,  sinuous,  undermined  edges,  having 
a  granulating  base,  and  extending  into  the  surrounding  cellular  tissue  or 
into  the  hypertrophied  muscular  coat.  The  suppuration  may  even  pass 
through  the  latter  by  means  of  sinuses,  in  the  vicinity  of  which  the  mucous 
membrane  presents  the  above-described  appearances,  or  is  blennorrhoic, 
and  often  covered  with  polypous  excrescences.  This  process  is  invariably 
accompanied  by  corrugation  and  slaty  or  bluish-black  discoloration  of  the 
intestinal  coats.  Catarrhal  phthisis  thus  occasions  a  contraction  of  the 
intestinal  canal,  which  becomes  more  considerable  after  the  cure  of  the 
former.  Cicatrization  is  effected  by  a  dense,  resisting  cellulo-fibrous 
tissue,  which  compresses  the  mucous  membrane  in  the  vicinity  of  the  loss 
of  substance,  or  the  solitary  insular  remnants  of  the  mucous  membrane, 
into  plicated  polypous  tumours. 

The  seat  and  extent  of  the  Catarrhal  inflammation  and  of  the  blennor- 
rhoea,  differ  according  to  the  cause.  They  are  frequently  spread  more 
or  less  uniformly  over  the  entire  intestinal  tract ;  they  are  often  limited 
to  a  certain  portion  of  the  colon  or  the  small  intestine,  where  they  occupy 
large  spaces  ;  or  they  may  occur"  in  one  or  several  small  circumscribed 
spots,  in  consequence  of  local  irritation.  These  affections  are  peculiarly 


INTESTINAL    CANAL.  61 

liable  to  recur  as  long  as  the  predisposing  cause  continues ;  they  exacer- 
bate from  time  to  time  if  chronic,  and  lead  to  suppuration.  They  are 
not  common  in  the  small  intestine,  their  usual  seat  being  certain  portions 
of  the  large  intestine,  viz.  the  caecum  and  rectum. 

A  peculiar  disease  that  we  must  here  advert  to  is  ulcerative  inflammation 
of  the  follicles  of  the  colon,  such  as  we  find  in  lientery,  brought  on  by 
tedious  diarrhoeas.  An  ulcer  results,  which  is  distinguished  from  the 
catarrhal  ulcer  just  described,  by  the  shape  which  it  derives  from  the 
follicle,  and  still  more  by  the  total  absence  of  reaction,  which  is  brought 
on  by  the  excessive  destruction  of  tissue,  and  which  produces  an  atonic 
and  relaxed  state  of  the  tissues  at  the  base. 

In  this  disease,  which  in  the  dead  subject  is  commonly  not  observed 
until  it  has  committed  extensive  ravages,  the  follicles  are  at  first  tumefied 
in  various  degrees,  and  consequently  project  as  smaller  or  larger  round, 
conical  nodules  on  the  internal  surface  of  the  intestine,  being  surrounded 
by  a  dark-red  vascular  halo.  Ulceration  now  ensues  in  the  interior  of 
the  follicle,  the  small  abscess  penetrates  the  mucous  membrane  within 
the  vascular  halo,  and  a  fringed  ulcerated  opening,  of  the  size  of  a  millet 
seed  appears,  which  leads  to  a  small  follicular  abscess  with  red  spongy 
walls.  The  ulceration  continues,  and  the  follicle  is  eaten  away.  The 
mucous  membrane  that  loosely  surrounds  the  enlarged  orifice  of  the 
abscess,  overlays  the  exposed  submucous  tissue.  In  most  cases  the 
hyperaemia  of  this  edge  diminishes  in  consequence  of  the  exhaustion 
brought  on  by  the  discharges ;  it  becomes  pale,  or  is  discolored  by  a  de- 
position of  black  pigment  in  its  tissue,  which  gives  rise  to  a  slaty  appear- 
ance. The  ulcer  is  of  the  size  of  a  pea  or  a  lentil,  round  or  oval,  the 
mucous  membrane  at  the  circumference  is  pale,  slate-colored,  livid,  and 
much  relaxed,  the  cellular  tissue  at  the  base  is  dull  white,  anaemic,  san- 
guineous or  dark  blue.  A  flabby  typhous  ulcer  of  the  colon  is  the  only 
thing  that  might  render  the  diagnosis  uncertain. 

At  this  period  a  secondary  destruction  of  the  intestinal  mucous  mem- 
brane commences,  which  proceeds  with  great  rapidity.  The  original 
follicular  ulcer  enlarges  in  every  direction,  forming  sinuses  and  exposing 
the  pale,  lax,  muscular  coat  at  its  base.  Several  ulcers  coalesce,  and  we 
thus  frequently  find  the  mucous  membrane  and  its  cellular  substratum 
destroyed  to  a  considerable  extent  and  the  remaining  portion  of  the 
mucous  membrane  pale  or  slate-colored ;  there  is  general  anaemia  and 
tabes ;  and  the  contents  of  the  intestinal  canal  consist  of  the  half-digested 
food  mixed  up  with  reddish,  semifluid,  grumous  matters. 

We  may  state  it  as  a  rule,  that  the  lower  down  the  original,  as  well  as 
the  secondary  process  takes  place,  the  more  fully  they  are  developed. 
Hence  the  most  extensive  destruction  is  found  to  occur  in  the  sigmoid 
flexure  and  the  rectum.  It  is  always  confined  to  the  colon.  Occasionally 
the  disease  runs  a  still  more  rapid  course,  as  in  infants  at  the  breast ; 
and  it  is  then  accompanied  by  catarrhal  irritation  of  the  small  intestine. 

On  account  of  the  alvine  discharges,  which  are  invariably  associated 
with  this  ulcer,  the  affection  may  not  inappropriately  be  termed  ulcera- 
tive diarrhoea. 

b.  Exudative  processes  of  the  intestinal  mucous  membrane. — Under 
this  head  we  include  all  those  products  of  serous,  albuminous,  pasty, 


62  ABNORMITIES    OF    THE 

fibrinous,  puriform,  and  purulent  exudation  occurring  on  the  mucous 
membrane,  which  are  more  or  less  profuse,  and  are  preceded  by  slight 
redness  and  congestion.  Maceration  and  solution  of  the  epithelium,  re- 
laxation, and  infiltration  of  the  mucous  and  submucous  tissues,  fusion 
(as  it  were  self-secretion)  and  gradual  disappearance  of  the  mucous 
membrane  and  its  follicles,  take  place  at  the  same  time.  The  mucous 
membrane  is  softened  and  tumid,  it  is  infiltrated  with  the  exuded  matter, 
variously  reddened  and  injected,  or  pale,  or  of  a  dirty  gray  or  tawny 
color.  In  proportion  to  the  degree  of  vascularity  and  the  quality  of  the 
exudation,  it  is  more  or  less  pultaceous,  and  attenuated  or  entirely  de- 
stroyed. 

We  here  also  adduce  the  process  that  takes  place  on  the  intestinal 
mucous  membrane  in  cholera,  the  acute  pituitous  condition  of  the  mucous 
membrane  (Eisenmann's  pyrotic  process),  genuine  croup,  puriform  and 
purulent  diarrhoeas,  &c. 

These  processes  probably  always  involve  a  large  tract  of  intestine,  and 
are  the  expression  of  a  constitutional  affection,  which  itself  may  either 
be  primary  or  secondary ;  in  the  latter  case  it  represents  a  degeneration 
or  an  anomalous  form  of  the  original  disease.  The  not  unfrequent  de- 
generations of  specific  cachexia,  such  as  typhus,  the  exanthemata  (par- 
ticularly variola  and  scarlatina),  acute  tubercle  and  cancer,  which  were 
originally  acute,  or  have  become  so  under  certain  conditions,  may  thus 
present  the  type  of  the  process  just  described. 

c.  The  Typhous  Process. — The  first  duty  of  the  pathological  anatomist 
in  this  case,  is  to  institute  a  comprehensive  investigation  of  the  local 
typhous  processes,  and  we  offer  the  results  derived  from  the  observation  of 
normal  ileo-typhus  as  it  is  presented  in  the  indigenous  form,  which  is 
commonly  very  defined  in  its  localization.  On  account  of  the  impor- 
tance of  the  subject,  we  shall  add  a  summary  of  the  changes  that  occur 
in  other  systems  and  organs  in  typhus,  as  wrell  as  a  synopsis  of  the  more 
important  anomalies  of  the  typhous  process,  that  we  are  at  present  ac- 
quainted with. 

The  Typhous  Process  in  the  Mucous  Membrane  of  the  Small 

Intestine. 

The  typhous  process  of  the  small  intestine  presents  four  stages : 

The  congestive  stage. 

The  stage  of  deposition  of  the  typhous  product, — of  typhous  infiltra- 
tion ;  the  crude  stage  of  the  deposit. 

The  stage  of  softening  and  rejection  of  the  typhous  deposit. 

The  stage  of  the  genuine  typhous  ulcer. 

In  the  first  stage,  which  corresponds  to  the  period  of  irritation  with  a 
predominance  of  catarrhal  and  gastric  symptoms,  we  observe  on  the  mu- 
cous membrane  of  the  small  intestine,  dilatation  and  stasis  in  the  venous 
system,  with  swelling,  and  a  peculiar  succulence  of  the  mucous  mem- 
brane, accompanied  by  opacity  and  slaty  discoloration.  The  swelling 
of  the  villous  layer  is  particularly  distinct.  This  condition  affects,  more 
or  less,  the  entire  mucous  membrane  of  the  small  intestine,  but  it  deve- 


INTESTINAL    CANAL.  63 

lopes  itself  more  strongly  at  some  parts  than  at  others,  and  there  generally 
appears  to  be  a  gradual  increase  from  above  downwards,  as  far  as  the 
csecal  valve.  The  inner  surface  of  the  intestine  is  invested  by  a  thick 
layer  of  dirty,  yellow,  gelatinous  mucus. 

The  mesenteric  glands  are  slightly  swollen,  their  bloodvessels  are  in- 
jected, the  tissue  itself  is  elastic,  soft  and  dark-colored. 

In  the  second  stage  the  congestion  is  diminished ;  the  injection  and 
reddening,  and  even  the  swelling  of  the  mucous  membrane,  retract  within 
circumscribed  spaces  which  correspond  with  Peyer's  agminated  glands, 
or  occasionally  with  solitary  follicles.  Rounded  or  more  commonly 
elliptical  tumefactions  (plaques),  varying  in  thickness  from  half  a  line  to 
three  lines,  are  formed,  which  result  from  the  deposition  of  a  peculiar 
substance  in  the  tissue  of  the  Peyerian  plexus  and  of  tfce  submucous  cel- 
lular tissue.  They  are  surrounded  by  a  vascular  wreath  which  stops 
short  at  their  circumference,  and  by  a  marginal  plane  which  rises  abruptly, 
or  is  contracted,  so  as  to  appear  pediculated.  In  the  latter  case  they 
the  more  resemble  flat  sessile  fungi,  as  they  often  present  an  umbilical 
indentation  at  their  centre.  According  to  the  amount  of  matter  accu- 
mulated, the  mucous  membrane  is  more  or  less  tense,  being  intimately 
blended  with  the  deposit,  as  this  again  is  firmly  and  immovably  attached 
to  the  muscular  coat  of  the  intestines. 

The  typhous  patches  offer  a  gray  or  tawny  discoloration,  which  is  per- 
ceptible through  the  mucous  membrane  as  well  as  through  the  two  exter- 
nal coats  of  the  intestine,  and  they  are  hard  and  resilient :  when  the  dis- 
coloration is  darker,  and  more  of  a  bluish-red  tint,  they  are  softer  and 
more  compressible.  They  appear,  when  seen  through  the  peritoneum, 
as  insulated  spots ;  they  may  be  generally  recognized  by  the  varicose 
condition  of  the  peritoneal  vessels,  and  they  are  perceptible  to  the  touch 
through  the  tumefaction  on  the  external  surface  of  the  intestine. 

The  lower  third  of  the  small  intestine  is  the  common  seat  of  typhous 
infiltration,  and  the  typhous  spots  are  placed  at  the  side  opposite  to  the 
insertion  of  the  mesentery ;  they  increase  in  number  towards  the  caecal 
valve.  They  vary  in  size  from  that  of  a  sixpence  to  half-a-crown ; 
towards  the  terminal  portion  of  the  small  intestine,  in  correspondence 
with  the  extensive  glandular  apparatus  that  exists  here,  they  occupy  a 
space  of  several  inches,  and  end  upon  the  ileal  surface  of  the  valve.  Near 
and  between  the  patches  we  find  single,  round,  nodulated  tumors  of  the 
size  of  a  hempseed  or  pea,  surrounded  by  a  similar  vascular  wreath ; 
these  represent  the  typhous  infiltration  of  a  solitary  follicle. 

On  minute  examination  of  the  morbid  product,  it  proves  to  be  deposited 
under  the  mucous  membrane  and  in  the  submucous  tissue,  without  involv- 
ing the  muscular  coat.  It  presents  a  substance  of  more  or  less  density, 
of  a  pale-red  color  and  fibro-lardaceous  texture ;  it  is  occasionally  tra- 
versed by  streaks  of  blood.  The  deposit  very  rarely  extends  beyond  the 
follicular  apparatus. 

The  swelling  of  the  mesenteric  glands  also  increases ;  they  are  of  the 
size  of  a  bean  or  hazelnut,  blue  or  bluish-red,  tolerably  firm,  and  appa- 
rently infiltrated  with  a  lardaceous  mass. 

The  commencement  of  the  third  stage  is  marked  by  a  return  of  violent 
congestion  to  the  small  intestine.  The  vessels,  and  especially  the 


64  ABNORMITIES    OF    THE 

of  the  mesentery  and  their  ramifications  between  the  intestinal  coats,  are 
filled  with  dark-purple  and  viscid  blood.  The  mucous  membrane  again 
swells,  the  villi  in  particular  tumefy,  and  on  pressure,  exude  a  grayish- 
white  opaque  serum. 

The  most  remarkable  change  is  now  effected  in  the  typhous  patches 
and  in  the  mesenteric  glands ;  they  soften.  The  patches  become  more 
tumefied,  and  if  the  softening  process  does  not  affect  them  uniformly, 
they  acquire  an  uneven  tuberculated  surface.  The  deposit  is  converted 
into  a  grayish-red  medullary  mass ;  this  may,  from  the  imbibition  of  bile, 
be  at  once  metamorphosed  into  a  dirty-yellow  or  brown  slough,  involving 
the  investing  mucous  membrane.  The  slough  shrivels  up  in  a  vertical 
and  lateral  direction,  becoming  loose  at  the  edges  and  pultaceous,  split- 
ting in  various  directions,  and  detaching  itself  from  the  lowest  stratum 
of  submucous  cellular  tissue,  by  which  means  it  is  wholly  or  in  part  dis- 
charged ;  or  the  morbid  product  degenerates,  when  the  epidemy  is  of  very 
intense  character,  into  a  loose,  vascular,  fungous  growth,  which  is  tra- 
versed by  streaks  of  extravasated  blood,  or  is  entirely  saturated  with  blood ; 
it  is  the  chief  source  of  profuse  intestinal  hemorrhages,  and  is  generally 
discharged  piecemeal  without  antecedent  sloughing. 

This  metamorphosis  sometimes  attacks  the  entire  patch,  sometimes  it 
only  affects  single  portions  or  separate  folliculi ;  in  the  latter  case  the 
remainder  of  the  patch  passes  through  a  retrograde  metamorphosis ; 
absorption  causes  it  to  collapse,  and  a  lax,  succulent,  plicated  tumefac- 
tion of  the  glandular  plexus  remains.  ^Accordingly,  the  above-mentioned 
slough  is  in  the  former  instance  embraced  by  the  mucous  membrane, 
which  invests  the  marginal  surface  of  the  typhous  patch  ;  in  the  latter, 
by  the  retrograde1  portion  (retrograder  antheil)  of  the  glandular  plexus. 

A  similar  metamorphosis  takes  place  in  the  tumefaction  of  the  solitary 
glands,  though  it  appears  to  commence  later,  and  to  advance  less  rapidly  ; 
the  sloughs  are  small  and  rounded,  and  seem  generally  to  undergo  the 
retrograde  process. 

This  metamorphosis  commences  in  the  neighborhood  of  the  csecal  valve, 
and  is  commonly  in  advance  of  that  which  takes  place  at  the  upper  part 
of  the  ileum. 

The  intestine  is  more  or  less  distended  with  gas  (meteorismus) ;  it  also 
contains  yellow  or  brownish  muco-gelatinous  or  biliary  matters,  mixed 
up  with  grumous,  furred  particles ;  it  always  occupies  a  low  position  in 
the  hypogastrium,  and  even  sinks  into  the  pelvic  cavity.  The  cagcum 
is  very  often  found  to  contain  the  trichocephalus  dispar  in  larger  or 
smaller  numbers. 

The  mesenteric  glands,  which  almost  invariably  pass  through  the 
stages  of  the  metamorphosis  with  less  rapidity  than  the  typhous  pro- 
ducts in  the  intestine,  now  attain  their  largest  bulk ;  they  reach  the  size 
of  pigeons'  eggs',  and,  in  the  vicinity  of  the  csecal  valve,  even  of  hens' 
eggs,  and  form  a  tuberculated  chain  which  extends  in  a  slanting  direc- 
tion from  the  terminal  portion  of  the  ileum  to  the  lumbar  plexus.  Their 

1  [The  terms  "  retrograde"  and  "  retrogression"  are  intended  to  designate  the  return  of  a 
diseased  part  to  its  normal  condition  by  absorption  of  the  deposit,  or  otherwise.  They  have 
been  adopted  from  the  absence  of  any  terms  which  exactly  convey  the  author's  meaning. 
-F4D.] 


INTESTINAL    CANAL.  65 

color  is  blue  or  bluish-red ;  they  are  much  congested,  and  the  vessels, 
spread  out  in  the  cellular  capsule  of  the  gland,  present  a  vascular  net- 
work which  is  perceptible  through  the  mesenteric  laminae.  Their  sub- 
•stance  is  firm,  but  they  are  soon  converted  into  a  grayish-red,  lax, 
medullary  matter,  in  which  we  frequently  discover  extensive  extravasa- 
tions of  blood ;  they  then  become  soft  and  elastic,  or  even  present 
distinct  fluctuation. 

Fourth  stage.  After  the  morbid  product  has  been  detached,  a  cavity 
remains  on  the  internal  surface  of  the  intestine,  which  represents  the 
true  typhous  ulcer. 

If  the  entire  morbid  growth  is  removed  at  once,  that  portion  of  the 
intestinal  mucous  membrane  which  invested  the  marginal  surface  of  the 
heterologous  product  sinks  down  upon  the  ulcer,  and  thus  forms  a 
mucous  fringe,  which  varies  in  width  and  extent  according  to  the  pre- 
vious elevation  (thickness)  of  the  morbid  growth  ;  and  from  being  at  first 
dark-red,  subsequently  assumes  a  blackish-blue  or  slate-gray  color.  If 
the  morbid  growth  has  only  been  partially  detached,  the  remaining  por- 
tion of  the  patch  becoming  retrograde,  we  find  the  smaller  ulcerated 
surface  equally  surrounded  by  a  margin  of  glandular  tissue. 

In  the  former  case  the  base  of  the  ulcer  corresponds  in  form  and  size 
to  the  previous  infiltration  (plaque) ;  varying  in  size,  it  is  either  round 
or,  more  frequently,  elliptic  ;  the  latter  shape  prevails  at  the  terminal 
portion  of  the  ileum,  and  the  long  diameter  of  the  ulcer  corresponds 
with  the  longitudinal  axis  of  the  intestine.  In  the  second  case  the  ulcer 
is,  at  all  events,  smaller  than  the  entire  Peyerian  gland,  its  shape 
irregular,  the  margin  sinuous  or  round.  Several  ulcers  are  often 
grouped  together.  For  the  typhous  infiltration  of  a  solitary  follicle  a 
circular  or  slightly  oval  ulcer  is  substituted. 

The  deep  submucous  cellular  layer,  which  invests  the  muscular  coat, 
forms  the  base  of  the  ulcer. 

The  mesenteric  glands  decrease  in  size,  as  soon  as  the  detachment  of 
the  intestinal  morbid  growth  has  commenced,  in  proportion  as  the  gray- 
ish-red medullary  substance,  with  which  they  are  infiltrated,  is  removed, 
though  they  still  continue  larger  than  they  are  in  the  healthy  condition ; 
in  consequence  of  the  enduring  congestion  and  enlargement  of  the 
vessels  they  present  a  reddish-blue  tinge. 

The  typhous  ulcer  consequently  presents  the  following  characters  : 

Firstly.  Its  form  is  elliptical  when  it  corresponds  to  the  infiltration 
and  detachment  of  a  larger  patch  of  Peyer's  glands ;  it  is  round  when  it 
corresponds  to  a  solitary  follicle  or  a  rounded  patch,  or  to  the  partial 
detachment  of  a  glandular  plexus ;  and,  lastly,  it  may  also  be  irregular 
or  sinuous  when  corresponding  to  a  partial  detachment. 

Secon-dly.  The  size  or  circumference  of  the  ulcer  varies,  from  that  of 
a  hemp-seed  or  a  pea  to  that  of  half-a-crown. 

Thirdly.  The  position  is  peculiar  in  reference  to  those  of  an  elliptical 
shape  ;  they  are  placed  opposite  to  the  insertion  of  the  mesentery,  and 
their  long  diameter  is  always  parallel  to  the  longitudinal  axis  of  the  in- 
testine ;  the  typhous  ulcer  never  forms  a  zone  ;  at  least,  we  have  only 
once  seen  this  occur  in  many  hundred  cases. 

VOL.   II.  5 


66  ABNORMITIES    OF    THE 

Fourthly.  The  margin  of  the  ulcer  is  invariably  formed  by  a  well-de- 
fined fringe  of  mucous  membrane,  which  is  a  line  or  more  wide,  detached, 
freely  movable,  of  a  bluish-red,  and  subsequently  of  a  slaty  or  blackish- 
blue  color. 

Fifthly.  The  base  of  the  ulcer  is  formed  by  a  delicate  layer  of  submu- 
cous  tissue  which  covers  the  muscular  coat ;  like  the  marginal  substance, 
it  is  quite  void  of  morbid  growth. 

Sixthly.  The  small  intestine  is  the  seat  of  the  ulcerative  process,  and 
the  lower  third  is  most  liable  to  be  involved — the  number  and  size  of  the 
ulcers  increase  as  they  advance  towards  the  caecal  valve. 

The  cure  of  the  typhous  ulcer  to  be  complete,  requires  several  local 
and  general  conditions,  of  which  the  chief  are  the  termination  of  the 
local  process,  and  the  complete  extinction  of  the  typhous  dyscrasia. 
When  such  favorable  circumstances  occur,  the  cure  is  effected  in  the  fol- 
lowing manner : 

The  fringe  of  mucous  membrane  which  lies  upon  the  base  of  the  ulcer, 
gradually  connects  itself,  from  without  inwards,  with  the  cellular  tissue 
that  invests  the  base,  and  uniting  with  it  becomes"  paler  and  thinner.  At 
the  same  time  the  cellular  layer  becomes  whiter  and  denser,  and  is 
finally  converted  into  a  serous  lamina,  the  circumference  of  which  is  dove- 
tailed between  the  muscular  and  mucous  coats.  The  margin  of  mucous 
membrane  is  bevelled  off  in  such  a  manner,  that  the  union  is  impercepti- 
ble ;  the  former  does  not  advance  uniformly  on  all  sides  towards  the 
centre  of  the  ulcer,  hence  the  ellipticaNs  converted  into  a  sinuous,  the 
round  into  an  elliptical  ulcer.  At  the  same  time  the  margin,  as  well  as 
the  neighboring  mucous  membrane,  are  thinned  down  in  such  a  manner, 
that  at  last  their  villi  appear  to  have  been  transferred  to  the  serous 
lamina.  The  edges  unite  finally  at  one  or  more  spots,  and  coalesce. 
We  have  sometimes  observed,  that  long  before  the  union  of  the  edges, 
small  villosities  formed  independently  on  the  serous  lamina,  a  fact  which 
has  been  also  remarked  by  Sebastian. 

Instead  of  the  ulcer  wre  find,  in  proportion  as  the  above  process  is 
effected,  a  slight  depression  on  the  internal  surface  of  the  intestine,  de- 
pendent upon  the  thinning  of  the  mucous  membrane  and  its  connection 
with  a  thin  cellular  layer  of  denser  structure, — or  we  find  a  spot  at  which 
the  mucous  membrane  is  more  firmly  attached  and  less  movable,  in  the 
middle  of  which,  by  oblique  light,  we  may  often  discover  a  smooth  re- 
mainder of  the  serous  lamina  of  the  size  of  a  millet-seed  ;  or,  if  even  this 
is  not  the  case,  we  discover  a  spot  at  which  the  mucous  membrane  is 
more  tense,  void  of  plicae,  smooth,  less  vascular  than  the  surrounding  por- 
tion, and  particularly  less  villous. 

Such  cicatrices  have  occasionally  been  observed  thirty  years  after  the 
typhus  had  occurred. 

It  is  singular,  and  characteristic  of  the  typhous  ulcer  and  its  cicatrix, 
that  it  never  in  any  way  gives  rise  to  a  diminution  of  the  calibre  of  the 
intestine. 

The  mesenteric  glands  in  the  meantime  have  returned  to  their  normal 
size ;  they  not  unfrequently  shrivel  up,  so  as  to  become  considerably 
smaller,  and  at  the  same  time  tough  and  pale. 


INTESTINAL    CANAL.  67 


Summary  of  the  Alterations  occurring  in  other  Organs. 

a.  In  the  abdominal  cavity. — We  find  that  here  only  the  spleen  and 
the  venous  system  of  the  fundus  ventriculi  offer  important  and  constant 
changes,  although  these  do  not  belong  exclusively  to  typhus,  and  still 
less  to  ileo-typhus. 

The  spleen  is  enlarged  to  from  twice  to  six  times  its  natural  size,  it 
swells,  and  its  sheath  becomes  tense  and  smooth  ;  the  tissue  of  the  organ 
is  friable,  and  contains  a  dark  purple  or  blackish-red,  semi-coagulated, 
pultaceous,  or  perfectly  fluid  mass,  which  gives  rise  to  a  tumor  of  pecu- 
liar appearance,  occasionally  communicating  the  sense  of  fluctuation ; 
not  ^infrequently  a  spontaneous  rupture  of  the  organ  ensues. 

At  the  fundus  ventriculi  we  find  venous  congestion,  which  may  be 
traced  back  to  the  vessels  of  the  spleen,  and  which  is  either  limited  to 
the  larger  trunks  or  affects  the  capillary  vessels  in  the  tissue  of  the 
mucous  membrane ;  ,in  the  latter  case,  the  mucous  membrane  of  the 
fundus  is  dark  red,  lax,  and  turgid,  and,  in  consequence,  similar  to  the 
condition  of  the  spleen,  rather  more  friable  than  in  the  normal  state. 
Allied  to  this  condition  is  the  first  stage  of  softening,  which,  however, 
does  not  appear  in  the  ordinary  course  of  typhus. 

b.  In  the  thorax. — The  bronchial  mucous  membrane  and  the  paren- 
chyma of  the  lungs  present  certain  constant  changes,  which,  however, 
vary  in  degree. 

The  former  is  affected  by  a  peculiar  catarrh,  accompanied  by  dark-red 
discoloration,  and  the  secretion  of  a  viscid  gelatinous  mucus,  which  in- 
creases in  amount  as  we  descend  to  the  smaller  subdivisions  of  the 
bronchi ;  the  pulmonary  parenchyma  presents  symptoms  of  hypostatic 
congestion,  which  is  generally  limited  to  the  posterior  and  lower  por- 
tions ;  the  tissue  appears  dark  red,  or  purple,  is  filled  with  dark-colored 
glutinous  blood,  is  denser,  and  resembles  the  spleen  in  consistency 
(splenification) ;  this  is  sometimes  increased  to  hepatization  (pneumonia), 
though  it  is  to  be  carefully  distinguished  from  secondary,  and  still  more, 
from  primary  pneumonic  typhus. 

The  heart  is  commonly  flaccid,  its  muscular  portions  are  pale,  or  of  a 
dirty-red  color,  but  without  any  further  anomaly,  and  more  especially 
without  that  softening  of  its  substance  des3ribed  by  Stokes  as  occurring 
in  the  typhus  fevers  of  Ireland.  The  endocardium  and  the  lining  mem- 
brane, or  all  the  coats  of  the  vascular  trunks,  frequently  present  a 
brown  or  purplish  discoloration  produced  by  imbibition. 

c.  Alterations  in  the  nervous  system. — The  brain  and  the  spinal  cord 
and  their  membranes  present  the  most  various  gradations  with  reference 
to  the  amount  of  blood  they  contain,  from  hypersemia  to  anaemia ;  they 
sometimes  are  characterized  by  remarkable  density  and  tenacity,  some- 
times by  a  humid  and  softened  condition. 

The  "double  condition  which  is  frequently  and  distinctly  seen  in  the 
central  ganglia  of  the  vegetative  system,  is  of  still  greater  importance, 
and  the  results  obtained  at  the  Viennese  Hospital,  since  the  year  1824, 
with  regard  to  this  question,  are  in  the  main  corroborated  by  the  obser- 
vations made  at  the  Wurzburg  school  of  medicine. 


68  ABNORMITIES    OF    THE 

The  ganglia  of  the  solar  and  superior  mesenteric  plexus  are,  in  the 
first  stages  of  typhus,  in  a  state  of  turgescence,  with  a  blue  or  greenish- 
red  discoloration ;  they  are  softened  in  the  ulcerative  stages,  and  sub- 
sequently we  find  them  collapsed,  pale,  flaccid,  shrivelled  up  as  it  were 
into  coriaceous,  tough,  white  or  grayish  masses. 

We  have  never  discovered  in  the  nervous  system  the  characters  of 
genuine  inflammation,  a  fact  which  is  also  established  by  the  investiga- 
tions of  Key,  in  opposition  to  those  of  Grossheim. 


Summary  of  the  most  remarkable  Anomalies  of  the  Local 
Typhous  Process. 

An  acquaintance  with  the  many  anomalies  of  this  process  is  of  such 
importance,  that  we  would  not  trust  a  person  ignorant  of  them  to  judge 
of  a  post-mortem  examination  in  a  case  of  acute  fever.  Their  diagnosis 
is  the  result  of  researches  which  we  have  for  many  years  devoted  to  the 
subject.  We  add  a  list  of  the  anomalies,  and  subjoin  the  most  essential 
explanations  at  once : 

1.  Anomalies  in  reference  to  the  amount  of  the  process  occurring  on 
the  intestinal  mucous  membrane. 

a.  Arrest  of  its  development.  % 

a.  Arrest  in  the  congestive  stage — diffused  typhous  process  in  the 
intestinal  mucous  membrane. 

/9.  Imperfect  development  of  the  patches — low  plasticity  of  the  mor- 
bid product.  This  variety  is  allied  to  the  diffused  form. 

f.  Retrogression  (retrogradwerden)  of  the  morbid  growths  by  absorp- 
tion ; — to  this  head  belong  Chomel's  plaques  d  surface  reticulee. 

d.  Slow  metamorphosis  of  the  morbid  growth,  tardy  separation  of  the 
slough,  and  purification  of  the  ulcer. 

£.  Scanty  formation  of  the  morbid  growth. 

b.  Excessive  development  of  the  local  process. 

a.  Tumultuous1  (tumultuarisch)  metamorphosis  of  the  morbid  growth, 
violent  congestion  of  the  intestine,  unusual  turgescence  of  the  morbid 
growths.  The  congestion  not  unfrequently  gives  rise  to  peritonitis, 
which  proceeds  from  one  of  the  patches ;  or  an  extravasation  of  blood 
occurs  between  the  intestinal  coats,  and  in  their  tissue ;  intestinal  apo- 
plexy, or  a  fungoid  degeneration  of  the  morbid  growths  takes  place, 
and  death  ensues  from  excessive  vegetation,  by  paralysis,  or  from 
exhaustion  by  hemorrhage  (hsemorrhagia  intestinalis). 

/?.  Numerous  formations  of  morbid  growths — extension  of  the  same 
to  the  solitary  follicles. 

f.  Extension  of  the  process  beyond  the  ileum  to  the  jejunum  and 
stomach,  or  to  the  colon.  * 

1  [The  German  word  "  tumultuarisch"  implies,  violent  symptoms  taking  place  with  sud- 
denness and  rapidity  •  Rokitansky  has  himself  used  the  term  in  a  new  sense  ;  the  translator, 
to  avoid  frequent  circumlocution,  has  therefore  ventured  to  employ  the  word  "tumultuous'" 
as  most  adapted  to  convey  the  author's  exact  meaning. — ED.] 


INTESTINAL    CANAL.  69 

2.  Anomalies  in  quality. 

a.  Impeded  cicatrization  of  the  ulcer — it  assumes  the  torpid  form. 

5.  Degeneration  into  a  perforating  typhous  ulcer. 

These  two  forms  constitute  genuine  typhous  intestinal  phthisis.  We 
have  seen  that  the  local  condition  for  the  cure  of  the  typhous  ulcer  con- 
sists in  a  complete  termination  of  the  local  morbid  process  in  the  intes- 
tinal mucous  membrane,  and  a  perfect  purification  of  the  ulcer  of  all 
morbid  growth,  and  that,  as  a  general  condition,  an  extirpation  of  the 
typhous  and  of  every  secondary  dyscrasia  is  required;  it  is  therefore 
evident  that  the  degenerations  of  the  typhous  ulcer  which  we  are  now 
considering  may  be  complicated  with  a  variety  of  anomalies ;  of  these 
some  have  already  been  considered. 

Perforation  of  the  intestine  by  the  typhous  ulcer  constitutes  a  very 
remarkable  phenomenon.  How  is  this  effected  ?  The  typhous  process 
invariably  meets  with  an  isolating  tissue  in  the  lower  stratum  of  the 
submucous  cellular  layer  and  of  the  muscular  coat;  the  destructive 
process  which  occurs  beyond  the  mucous  membrane,  is  therefore  not  the 
result  of  a  previous  typhous  affection  (infiltration),  but  of  an  essentially 
distinct  process.  It  is  this  that  affords  a  marked  distinction  between 
the  perforating  typhous  and  the  perforating  tubercular  ulcer.  The  pro- 
cess by  which  perforation  of  the  intestinal  parietes  at  the  base  of  the 
ulcer  is  effected,  is  softening  or  mortification  of  the  tissue ;  the  slough 
that  results  only  affects  the  deepest  parts  of  the  ulcer  to  a  small  extent, 
and  we  rarely  find  the  orifice  larger  than  a  pin-hole,  or  a  millet  or  hemp- 
seed. 

The  varying  period  at  which  in  the  course  of  typhus  the  ulcer  dege- 
nerates in  this  manner,  is  remarkable,  as  also  the  rapidity  with  which 
occasionally  the  perforation  is  effected.  We  have  observed  it  occur 
rapidly  in  ulcers  that  had  scarcely  formed,  whilst  the  remaining  morbid 
growths  were  engaged  in  the  metamorphosis,  or  even  in  the  crude  stage ; 
and  again  we  have  seen  it  occur  slowly  or  quickly  at  every  subsequent 
stage ;  long  after  the  termination  of  the  local  process,  and  even  after 
the  genuine  typhous  had  subsided  into  the  atonic  ulcer. 

The  consequence  of  the  intestinal  perforation,  and  of  the  resulting 
effusion  of  the  intestinal  contents  into  the  peritoneal  cavity  is  peritonitis  ; 
it  generally  gives  rise  to  tolerably  copious,  but  uncoagulable  and  liquid 
exudation ;  it  frequently  takes  place  even  before  actual  perforation  has 
ensued,  and  is  developed  as  soon  as  the  process  of  perforation  approaches 
the  peritoneum. 

The  exudation  commonly  induces  an  adhesion  between  the  perforated 
coil  and  another  coil,  or  between  its  mesentery  and  the  pelvic  parietes ; 
which  may  certainly  be  looked  upon  as  an  effort  of  the  vis  medicatrix 
naturce,  but  which  our  investigations  have  proved,  never  to  effect  a 
radical  cure  of  the  typhous  perforation  of  the  intestine. 

Our  experience  with  regard  to  the  perforating  process,  does*  not,  except 
in  rare  cases,  allow  us  to  concur  in  the  view  adopted  by  several  French 
observers  of  distinction,  that  it  is  to  be  considered  as  a  rupture  of  the 
ulcerated  part ;  nor  can  we  sanction  the  doctrine  of  Judas,  that  the  intes- 
tine, when  on  the  point  of  being  perforated,  moves  into  the  pelvic  cavity, 
in  order  to  find  suitable  spots  for  adhesion,  inasmuch  as  the  typhous  intes- 


70  ABNORMITIES    OF    THE 

tine  sinks  into  the  lowest  region  of  the  abdominal  cavity  long  before  the 
ulcerative  degeneration  takes  place. 


Appendix. — Anomalies  in  reference  to  the  Degree  and  Character  of  the 
Typhous  Process  in  the  Mesenteric  Crlands. 

1.  Tumultuous  metamorphosis  of  the  typhous  product  in  the  mesen- 
teric  glands. 

This  sometimes  consists  in  very  violent  congestion  of  the  gland,  which 
not  unfrequently  gives  rise  to  inflammatory  injection  of  the  mesenteric 
laminae  above  the  gland ;  or  great  tumefaction  takes  place,  and  the  gland 
is  converted  into  a  medullary,  ichorous  pulp  ;  or,  lastly,  a  fungous  growth 
forms,  which  perforates  one  of  the  mesenteric  laminae,  commonly  the 
anterior  one.  General  peritonitis  is  a  frequent  consequence  of  these 
occurrences ;  in  the  last  instance  we  have,  as  in  the  case  of  intestinal 
hemorrhages,  extravasations  into  the  peritoneal  sac.  This  anomaly  gene- 
rally occurs  in  a  gland  that  is  seated  near  the  termination  of  the  ileum, 
and  is  accompanied  by  a  tumultuous  metamorphosis  in  the  intestinal 
mucous  membrane. 

2.  Atrophy  of  the  mesenteric  glands. 

The  involution  of  the  mesenteric  glands  after  the  termination  of  the 
typhous  process  is  sometimes  carried  to  Excess,  and  an  atrophy  of  these 
glands  results.  They  then  appear  shrivelled,  flaccid,  coriaceous,  per- 
fectly bloodless,  pale  or  gray,  or  even  of  a  dark  blue  color.  Occasionally 
the  atrophy  is  less  perceptible,  as  the  gland  appears  of  its  normal,  or 
even  beyond  its  normal  size ;  this,  however,  is  only  the  consequence  of 
passive  congestion  or  stasis,  from  dilatation  of  the  vessels,  which  are  full 
of  blood,  and  give  it  a  bluish-red  color,  the  glandular  tissue  itself  being 
diminished. 

The  typhous  ulcer  of  the  intestine  at  the  same  time  assumes  a  torpid 
condition,  or  it  may  have  advanced,  in  some  measure,  to  cicatrization. 

We  shall  show  at  a  future  period  how  this  condition  forms  an  impor- 
tant anatomical  basis  for  the  constitutional  debility  consequent  upon 
typhus. 

3.  Secondary  typhous  processes. 

An  acquaintance  with  these  processes  is  the  more  important,  as  they 
throw  much  light  upon  the  nature  of  typhus,  as  they  have  hitherto  been 
but  little  known,  and  as  their  connection  with  the  primary  disease  is 
commonly  overlooked.  They  almost  invariably  present  anomalies  in  re- 
ference to  the  seat  of  the  typhous  process ;  several  of  them  are  remarka- 
ble for  the  frequency  of  their  occurrence.  They  are  to  be  distinguished 
either  as  genuine  or  as  degenerated  typhous  processes. 

Genuine  secondary  typhous  processes  generally  depend  upon  marked 
anomalies  in  the  degree  of  the  primary  process.  The  most  exquisite 
form  in  which  they  present  themselves  is  seen  in  the  mucous  membranes, 
which  we  must  consider  as  the  true  nidus  of  the  typhus. 

a.  Secondary  processes  in  mucous  membranes. 


INTESTINAL    CANAL.  71 

«.  Kecurrent  eruption  of  the  mucous  membrane  of  the  small  intestine. 
— We  may  find  typhous  patches  of  recent  formation  in  the  crude  stage, 
intervening  among  typhous  formations  which  are  undergoing  the  metamor- 
phosis or  at  the  side  of  the  typhous  ulcer.  These  must  be  carefully  dis- 
tinguished from  the  patches  which  are  less  advanced  in  their  development. 
This  eruption  is  occasionally  seen  in  a  very  undeveloped  state,  in  the 
form  of  miliary  swelling  of  the  solitary  follicles. 

,3.  Secondary  typhous  process  in  the  mucous  membrane  of  the  colon 
and  stomach ; — secondary  colo-typhus,  secondary  gastric  typhus. — The 
latter  is  a  rare  occurrence  ;  it  stops  short  at  the  congestive  stage  when  it 
does  take  place,  and  very  rarely  presents  the  nodulated  form  of  the  typhous 
deposit. 

Y.  Secondary  laryngeal  typhus. — This  is  a  secondary  typhous  process 
of  considerable  importance,  both  on  account  of  its  frequency  and  on  ac- 
count of  its  unfavorable  prognosis.  Its  seat  is  the  posterior  surface  of 
the  larynx  and  the  edges  of  the  epiglottis ;  it  not  unfrequently  gives  rise 
to  typhous  laryngeal  phthisis,  accompanied  by  necrosis  of  the  cartilages. 

d.  Secondary  pharyngeal  typhus  occurs  much  more  rarely  than  the 
former,  and  never  except  in  company  with  it. 

e.  Secondary  bronchial  and  pneumonic  typhus. 

This  must  be  carefully  distinguished  from  the  hypostatic  pneumonia 
frequently  developed  in  the  course  of  typhus,  as  well  as  from  capillary 
phlebitis  of  the  lungs. 

£.  Secondary  typhous  process  in  the  vesical  mucous  membrane. 

77.  Secondary  typhous  process  in  the  mucous  membrane  of  the  female 
sexual  organs. 

~b.  Secondary  typhous  processes  in  serous  membranes. — Among  these 
we  reckon  the  typhous  inflammations  of  the  pleura,  of  the  meninges,  of 
the  capsule  of  the  aqueous  humor,  and  of  the  internal  coat  of  the  vessels 
(Phlebitis  typhosa). 

c.  Secondary  typhous  processes  in  parenchymatous  organs. — These 
are  the  typhous  inflammations  of  the  liver,  the  spleen,  the  parotid,  and 
the  ganglionic  substance  of  the  brain  and  spinal  cord. 

The  degenerated  secondary  typhous  process  occurs  in  various  forms ; 
in  almost  all  of  them  a  suspicion  arises  of  the  existence  of  a  disease 
analogous  to  typhus,  and  this  fact  offers  the  more  interest,  as  we  have 
arrived  at  similar  results  in  our  special  investigations  of  the  morbid 
anatomy  of  ileo-typhus.  Autenrieth  describes  them  as  neuroparalytic 
inflammations,  Schonlein  as  neurophlogoses,  Eisenmann  as  pyra,  Buzorini 
under  the  head  of  typhus.  They  are  based  upon  a  corresponding  de- 
generation of  the  typhous  process  in  the  blood,  and  may  be  classed  as 
follows  : 

a.  Degeneration  into  croupy  inflammation. — This  includes  the  entire 
exudative  processes  of  the  mucous  membrane,  of  the  respiratory  organs, 
the  oesophagus,  the  stomach,  the  intestinal  canal,  the  female  sexual 
organs ;  as  well  as  all  the  secondary  exudative  processes  occurring  on 
serous  membranes ;  and  the  exudations  that  ensue  on  the  cellular  and 
muscular  base  of  the  typhous  ulcer,  as  a  degeneration  of  the  local  affec- 
tion of  the  intestinal  mucous  membrane. 

0.  Degeneration  into  acute  softening. — To  this  class  belong  first  of  all 


72  ABNORMITIES    OF    THE 

the  remarkable  and  frequent  cases  of  black  ramollissement  of  the  fundus 
ventriculi  and  the  oesophagus  in  which  the  spleen  sometimes  participates, 
and  which  originates  in  the  vascular  system  ;  and  in  a  second  degree  the 
softening  of  the  pulmonary  parenchyma,  and  of  the  mucous  membrane  of 
the  bladder.  When  occurring  as  a  degeneration  of  the  local  process,  it 
is  found  at  the  base  of  the  typhous  ulcer,  and  may  superinduce  perfora- 
tion of  the  intestine.  (Vid.  p.  69.) 

Y.  Degeneration  into  gangrenous  inflammation  and  primary  gangrene. 
— This  includes  the  well-known  phenomena,  occurring  in  the  course  of 
typhus  in  the  shape  of  noma,  gangrsena  pulmonum,  sloughing  of  the  nates 
(decubitus),  of  parts  to  which  vesicants  have  been  applied,  and  of  the 
female  sexual  organs.  It  may  occur  as  a  degeneration  of  the  local  pro- 
cess, and  by  sloughing  at  the  base  of  the  typhous  ulcer  induce  perforation 
of  the  intestine. 

d.  Degeneration  into  a  process  in  which  pus,  or  rather  a  fluid  analo- 
gous to  pus  is  formed. — This  involves  suppuration  of  the  patches  and  of 
the  typhous  ulcer,  in  the  mesenteric  glands ;  as  well  as  suppuration  in  the 
lungs,  the  spleen,  the  liver,  the  parotid,  in  the  subcutaneous  cellular  tissue, 
between  the  muscles,  &c. 

Besides  these  anomalies,  there  are  other  sequelae  of  typhus,  which  are 
based  upon  a  permanent  depression  of  the  entire  vegetative  system,  such 
as  tabes  universalis ;  or  upon  a  diminution  of  nervous  power,  as  obtuse- 
ness  of  the  senses  or  paralysis ;  or  again  upon  continued  irritation,  as 
hydrocephalus ;  or  lastly,  upon  a  secondary  constitutional  disease,  as 
presented  in  oedema,  anasarca,  permanent  suppurative  processes,  and 
Bright's  renal  disease. 

The  depression  of  the  vegetative  system  remaining  after  typhus  de- 
mands special  investigation.  It  is  presented  either  as  a  very  slow  pro- 
gress of  convalescence,  or  in  the  advanced  degree  as  genuine  tabes  ;  both 
forms  are  distinguished  by  their  peculiar  type.  The  following  are  the 
anatomical  points  which  characterize  them  : 

a.  Genuine  intestinal  phthisis,  or  wrhere  a  cure  of  the  intestinal  ulcers 
has  begun,  or  is  almost  terminated,  a  loss  of  villi  and  follicles ; 

J3.  A  shrivelled  condition  or  marasmus  of  a  considerable  number  of 
mesenteric  glands ;  and 

Y*  The  flaccid  atrophic  condition  of  the  abdominal  ganglia,  and  more 
especially  of  the  solar  and  superior  mesenteric  plexus,  which,  as  well  as 
the  former,  we  have  already  adverted  to. 

EPICRISIS. 

Firstly.  Typhus  is  characterized  anatomically  and  in  reference  to  thei 
alterations  in  the  solids,  by  the  deposition  of  a  peculiar  product,  which 
undergoes  a  peculiar  metamorphosis. 

Secondly.  Its  habitat  varies  and  depends  upon  the  specific  relation 
existing  between  the  general  disease  and  certain  organs.  Indigenous  as 
well  as  exotic  typhus  show  the  mucous  membranes  and  the  lymphatic 
glands  to  be  the  chief  seat ;  in  Austria  it  is  chiefly  the  mucous  membrane 
of  the  small  intestine,  yet  even  here  bronchial  and  pneumonic  typhus 
occur  as  a  primary  affection,  and  ought  probably  to  be  considered  as  the 


INTESTINAL    CANAL.  73 

basis  of  the  exanthematic  form ;  we  also,  though  very  rarely,  meet  with 
colo-typhus. 

Thirdly.  The  product  of  typhus  presents  in  its  first,  but  still  more,  in 
its  later  stages  of  metamorphosis,  the  greatest  analogy  with  cancerous 
growths,  and  more  particularly  with  medullary  cancer.1 

Fourthly.  The  local  typhous  process  is  a  species  of  inflammation ;  but 
not  one  of  those  to  which  we  attribute  a  phlogistic  crasis  of  the  blood, 
but  one  which,  on  account  of  the  peculiar  diseased  condition  of  the  blood, 
we  term  typhous. 

Fifthly.  The  local  affection  of  the  mucous  membrane  of  the  small  in- 
testine, is  a  constant  accompaniment  of  the  typhus  seen  among  our- 
selves ;  but  as,  according  to  our  previous  observations,  it  may  occasion- 
ally be  subject  to  an  arrest  of  development,  we  find  solitary  exceptions 
in  which  there  is  no  intestinal  affection ;  in  that  case  it  is  necessary  to 
watch  the  other  mucous  membranes  closely,  or,  indeed,  the  process,  with- 
out being  localized,  may  run  its  entire  course  in  the  blood. 

It  is  well  known  that  typhus  occurs  chiefly  during  the  period  of  puberty 
and  during  the  prime  of  life ;  before  and  after  this  epoch,  it  is  very  un- 
frequent ;  we  must  however  guard  against  considering  every  typhoid  ap- 
pearance in  Peyer's  patches,  during  the  early  years  of  life,  as  genuine 
typhus.  The  predisposition  seems  to  disappear  with  the  involution  of  the 
sexual  powers ;  still  it  does  occur  now  and  then,  after  the  sixtieth  and 
seventieth  years  of  life. 

Typhus  presents  a  peculiarly  interesting  negative  relation  in  reference 
to  its  capability  of  forming  combinations.  Pregnancy  offers  an  almost 
entire  immunity  from  typhus,  lactation  less  so,  and  cases  in  which  it  is 
complicated  with  tubercular  affections,  with  cyanosis,  cancer  and  the 
cancerous  cachexies  are  exceptional,  whereas  it  is  frequently  complicated 
with  syphilis  and  gonorrhoea. 

d.  The  Dysenteric  Process* — We  are  acquainted  with  the  dysenteric 
process  as  a  substantive  disease  of  the  mucous  membrane  of  the  colon, 
and  inasmuch  as  it  is  here  presented  in  its  most  exquisite  form,  its  habitat 
has  been  correctly  fixed  ever  since  the  days  of  Hippocrates. 

The  dysenteric  process  is  divisible  into  four  natural  degrees  or  forms. 

In  the  lowest  degree,  the  mucous  membrane  commonly  presents  a  layer 
of  a  thin  secretion,  of  a  dirty  gray  and  reddish  color,  underneath  which, 
certain  parts,  commonly  the  projecting  folds  of  the  mucous  membrane, 
are  reddened  and  swollen.  In  this  manner  striae  are  produced,  which 
more  or  less  encircle  the  intestine.  The  epithelium  is  either  raised  in 
the  shape  of  small  vesicles  which  contain  clear  serum,  or  it  forms  a  gray- 
ish-white layer,  resembling  the  mealy  scurf  of  the  epidermis,  an  appear- 
ance which  probably  induced  Linnaeus  to  term  dysentery  Scabies  intesti- 
norum  internet.  The  subjacent  mucous  membrane  seems  excoriated, 
slight  pressure  induces  hemorrhage,  and  it  may  be  easily  detached  in  the 
shape  of  a  light  red  sanguineous  pulp ;  its  submucous  cellular  tissue 
appears  infiltrated. 

1  We  must  leave  a  further  development  of  this  doctrine  to  oral  instruction.     Dr.  Mohr,  in 
his  Contributions  to  Pathological  Anatomy  (Stuttgart,  1838,  p.  131),  quotes,  in  connection 
with  this  subject,  an  authority  which  is  quite  foreign  to  the  matter. 

2  Vide  Oestr.  Jahrb.  xx.  I. 


74  ABNORMITIES    OF    THE 

The  anatomical  characters  may  be  summed  up  as — swelling,  injection 
and  reddening,  softening  (red  and  bleeding),  serous  exudation  in  the 
shape  of  a  delicate  vesicular  eruption  and  consequent  branny  desqua- 
mation  of  the  epidermis. 

In  the  second  degree,  the  textural  alterations  are  not  limited  in  the 
manner  described,  but  extend  over  a  larger  surface,  still,  however,  pre- 
senting a  greater  development  at  one  part  than  at  another.  The  mucous 
membrane  is  invested  to  the  same  extent,  by  a  dirty-gray  layer,  consist- 
ing of  desquamated  epithelium  and  a  thick  glutinous  exudation ;  or  this 
may  already  have  been  removed,  and  the  subjacent  mucous  membrane, 
in  either  case,  appears  converted  into  a  soft,  sanguineous,  pale-red  and 
yellowish  gelatinous  substance,  which  may  be  easily  detached.  The  in- 
ternal surface  of  the  intestine  commonly  presents  more  or  less  numerous 
protuberances,  which  closer  examination  proves  to  consist  of  a  very 
copious  infiltration  of  the  submucous  cellular  tissue  :  these  projections  or 
tumors  were  first  observed  by  Hewson  and  Pringle  ;  other  authors  speak 
of  them  as  warty  tubercular  swellings,  or  fungoid  excrescences,  and  M. 
Gely  has  lately  termed  them  Hypertropliie  mamelonnee  du  tissue  sous- 
muqueux. 

They  correspond  to  those  points  of  the  mucous  membrane  at  which 
the  morbid  affection  is  most  developed ;  with  the  exception  of  slight  red- 
ness and  intumescence,  especially  in  the  circumference  of  the  follicles,  an 
increase  in  the  mucous  secretion,  and  a  slight  desquamation  of  epithelium, 
the  intervening  parts  of  the  mucous  membrane  do  not  generally  offer  any 
marked  textural  changes.  The  entire  portion  of  intestine  is  generally  in 
a  state  of  passive  dilatation  ;  it  is  distended  with  gas  and  with  a  dirty 
brown  fluid,  which  consists  of  the  most  different  materials,  such  as  intes- 
tinal secretions,  epithelium,  lymph,  blood,  and  fseces  ;  its  coats  are  thick- 
ened, and  the  submucous  tissue  particularly  is  in  a  state  of  tumefaction. 

At  this  stage  we  meet  with  the  laminated  and  tubular  coagula  in  the 
evacuations,  described  by  ancient  and  modern  authors,  especially  if  the 
exudation  be  of  a  more  plastic  character. 

Occasionally  the  affection  of  the  follicles  predominates  and  is  accom- 
panied by  irritation,  exhausting  secretions,  and  softening  :  these  probably 
constitute  the  characteristic  signs  of  the  so-called  catarrhal  or  white 
dysentery,  but  which,  in  an  anatomical  point  of  view,  is  the  same  folli- 
cular  affection  of  the  colon  as  that  which  we  have  already  described  as 
accompanying  chronic  diarrhoea. 

In  the  third  stage,  we  find  the  protuberances  more  closely  set,  so  as 
to  produce  an  uneven,  lobulated  appearance.  The  mucous  membrane 
that  invests  these  protuberances  partly  retains  the  above-described  con- 
formation ;  in  part  it  is  converted  into  a  slough,  which  is  here  and  there 
blended  with  the  desquamated  epithelium  and  the  exudation,  and  is  firmly 
attached  to  them  ;  it  is  of  a  dark-red  or  blackish-brown,  sugillated,  or 
grayish-green  color  ;  or  the  mucous  membrane  may  have  disappeared, 
so  as  to  expose  the  infiltrated  submucous  cellular  tissue,  to  which  the 
remnants  of  the  mucous  membrane  remain  attached  in  the  shape  of 
solitary,  dark-red,  flaccid,  and  bleeding  vascular  tufts,  or  as  dilated 
follicles,  which  are  easily  removed.  The  interstices  of  the  mucous 
membrane  are  the  seat  of  the  affection  in  a  lower  degree. 

The  protuberances  occasionally  are  found  to  have  coalesced,  and  the 


INTESTINAL    CANAL.  75 

intestine  then  presents  an  uneven  plicated  surface,  accompanied  by  an 
equable  degree  of  infiltration  and  thickening  of  its  parietes ;  the  mucous 
membrane  is  uniformly  affected  over  a  large  extent,  and  there  are  no 
free  interstices. 

The  contents  of  the  intestine  are  of  a  dirty-brown  or  reddish,  ichorous, 
fetid,  flocculent  and  grumous  character. 

In  the  fourth  and  highest  degree,  the  mucous  membrane  degenerates  into 
a  black,  friable,  carbonified  mass,  which  may  often  be  subsequently  voided 
in  the  shape  of  tubular  laminae  (so-called  mortification  of  the  mucous  mem- 
brane). The  submucous  cellular  tissue  appears  to  be  previously  infiltrated 
with  carbonified  blood,  or  a  sero-sanguinolent  fluid ;  or  it  is  pallid,  and  the 
blood  contained  in  its  vessels  is  converted  into  a  black,  solid  or  pulveru- 
lent mass :  subsequently  it  shows  purulent  infiltration,  in  consequence  of 
the  reactive  inflammation  which  is  induced  in  the  lower  healthy  strata, 
for  the  purpose  of  eliminating  the  gangrenous  portions. 

The  affected  portion  of  intestine,  which  contains  a  putrid,  brownish- 
black  fluid,  resembling  coffee-grounds,  may  appear  in  a  state  of  passive 
dilatation,  as  above  described,  but  it  is  much  more  frequently  collapsed  ; 
and  if  the  two  highest  degrees  continue  for  any  length  of  time,  the  mus- 
cular coat  will  be  reduced.  The  tissue  of  the  latter  is  condensed,  pale, 
ashy,  peculiarly  elastic  and  friable,  and  analogous  to  the  yellow  fibrous 
tissue. 

The  peritoneal  coat  presents,  in  the  higher,  and  particularly  in  the 
highest  degree  of  the  affection,  a  dirty-gray  discoloration,  and  a  total 
absence  of  lustre  ;  at  intervals  it  presents  a  dilatation  and  injection  of  its 
capillary  vessels,  and  is  invested  with  a  brownish,  ichorous  exudation ; 
occasionally  the  meso-colon,  and  even  the  mesenteric  laminae,  that  have 
been  in  contact  with  them,  participate  in  the  affection.  This  affords  a 
means  of  distinguishing  dysenteric  disease  of  the  intestine  on  its  outer 
surface. 

The  glands  of  the  meso-colon  present  a  corresponding  tumefaction ; 
they  are  of  a  dark-blue  color,  congested  and  tumefied ;  but  we  have  not 
succeeded  in  detecting  in  them  a  peculiar  (specific)  solid  morbid  product, 
as  we  have  in  typhus. 

The  mucous  membrane  of  the  colon  is,  as  we  have  already  observed, 
the  seat  of  the  dysenteric  process ;  and  we  may  state  it  as  a  rule,  that 
its  intensity  increases  from  the  csecal  valve  downwards,  and  consequently 
is  met  with,  in  the  most  fully-developed  state,  in  the  sigmoid  flexure  and 
in  the  rectum.  It  not  unfrequently  passes  beyond  the  caecal  valve, 
towards  the  ileum,  but  is  here  only  seen  in  its  mildest  form. 

It  commonly  runs  an  acute  course,  though  it  is  frequently  chronic  in 
the  milder  degrees  ;  this,  however,  does  not  materially  alter  its  character. 

The  manner  in  which  it  terminates  varies. 

1.  The  disease  is  fatal,  in  consequence  of  the  more  or  less  rapid,  or 
more  or  less  penetrating  destruction  of  tissue,  and  the  coincident  exhaus- 
tion. 

2.  The  disease  may  terminate  in  cure,  if  the  mucous  membrane  has 
not  become  disorganized  in  the  manner  above-described,  the  normal  cohe- 
sion returning,  and  a  new  layer  being  generated  under  the  desquamated 
epithelium. 


76  ABNORMITIES    OF    THE 

3.  In  the  higher  degrees  of  the  disease,  when  disorganization  has  oc- 
curred in  one  of  the  above-described  processes,  and  the  mucous  mem- 
brane has  suffered  more  or  less  extensive  destruction,  one  of  two  results 
ensues : 

a.  A  real  cure  of  the  loss  of  substance,  with  consolidation  of  the 
abraded  portions  of  the  intestine  follows  ;  or, 

5.  The  entire  process  assumes  a  low  chronic  form,  the  specific  nature 
of  the  disease  is  lost,  and  we  have  atonic  inflammation  and  suppuration 
of  the  intestinal  coats. 

If  a  cure  ensues,  the  portions  of  mucous  membrane  which  were  affected 
in  a  lower  degree  are  first  restored  to  their  normal  condition ;  between 
them  are  small  patches,  or  more  extensive  spaces,  with  a  sinuous  circum- 
ference, at  which  the  mucous  membrane  is  deficient,  and  the  submucous, 
pale,  infiltrated  cellular  tissue  is  exposed.  Not  unfrequently  we  perceive 
detached  remnants  of  mucous  membrane  adhering  to  these  parts.  The 
exposed  submucous  cellular  tissue  is  gradually  converted,  as  proved  by 
cadaveric  examinations  at  the  most  various  periods  after  the  cessation  of 
dysentery,  into  serous  tissue  ;  this  is  further  condensed  into  sero-fibrous 
tissue,  and  by  it  the  sinuous  portions  of  mucous  membrane,  at  the  edge  of 
the  impaired  surface,  are,  like  the  isolated  remnants  of  mucous  membrane, 
compressed  into  warty,  pediculated  (polypous)  prolongations,  and  thus 
the  originally  sinuous  circumference  obtains  a  fringed,  dentated  appear- 
ance. In  cases  in  which  the  loss  of  substance  is  inconsiderable,  the  new 
tissue  may  contract  so  as  to  bring  thte  edges  of  the  mucous  membrane 
into  apposition  with  one  another  and  with  the  polypous  remnants  of  mu- 
cous membrane,  and  the  cicatrix  is  then  represented  by  a  large  number 
of  agminated  warty  excrescences  of  the  mucous  membrane,  between 
which  the  sero-fibrous  basis  from  which  they  proceed,  may  be  detected. 

In  cases  of  extensive  destruction  of  substance,  the  approach  of  the  edges 
is  rendered  impossible ;  the  deeper  layers  of  the  tissue,  which  takes  the 
place  of  the  mucous  membrane,  is  frequently  condensed  into  fibrous 
bands,  which  form  corded  projections  into  the  intestinal  cavity,  interlace 
with  one  another,  and  not  unfrequently  encroach  upon  the  calibre  of  the 
intestine  in  the  shape  of  valvular  or  annular  folds,  thus  giving  rise  to  a 
stricture  in  the  colon  of  a  very  peculiar  form.  This  mode  of  regenera- 
tion is  the  more  remarkable,  as  it  closely  resembles  that  following  the 
destruction  of  the  oesophageal  mucous  membrane  by  mineral  acids. 

In  the  second  case  the  specific  affection  terminates  after  having  pre- 
viously given  rise  to  more  or  less  extensive  disorganization,  but  without 
being  followed  by  the  healing  process  just  described.  The  entire  disease 
now  assumes  a  chronic  character,  and  appears  on  the  residual  portion  of 
mucous  membrane  as  chronic  catarrhal  inflammation,  the  follicles  being 
more  or  less  prominently  affected,  and  suppuration  occurring  in  the  shape 
of  sinuses  and  abscesses  under  the  mucous  membrane,  and  between  the 
external  coats  of  the  intestine  ;  at  the  same  time  the  intestinal  canal  con- 
tracts, its  coats  assume  a  rusty,  dark-blue  color;  there  is  occasional 
exacerbation  of  the  peritoneal  irritation,  and  the  intestine  becomes  fixed 
in  consequence  of  exudation  and  infiltration  in  its  cellular  sheath  and  its 
mesentery.  In  this  case  the  mucous  membrane  is  found  of  a  dull,  red 
color,  tumefied,  and  invested  by  a  copious  secretion  of  a  glairy  or  purulent 


INTESTINAL    CANAL.  7T 

character ;  the  follicles,  particularly  those  at  the  end  of  the  colon,  are 
dilated,  distended  hy  a  glassy  pituita,  or  in  a  state  of  suppuration ;  there 
are  small  abscesses,  of  the  size  of  a  hemp-seed  or  pea,  under  the  mucous 
membrane,  and  in  the  cellular  tissue  lying  between  the  muscular  fibres. 
These  abscesses  open  upon  the  mucous  membrane  by  the  suppurating 
follicles  or  by  other  minute  orifices,  forming  fistulous  passages  in  various 
directions,  and  penetrating  into  deeper  parts,  so  as  to  reach  the  peri- 
toneum, and  there  induce  inflammation  ;  or  they  give  rise,  in  the  vicinity 
of  the  rectum,  to  the  formation  of  large  abscesses,  as  described  by  Mor- 
gagni. 

The  concurrent  contraction  of  the  intestinal  tube  probably  causes  in 
this  case,  also,  a  diminution  of  its  calibre,  but  this  form  presents  no 
peculiarity  to  distinguish  it  from  the  effect  which  may  be  produced  in 
every  case  of  catarrhal  inflammation  attended  by  repeated  exacerbations. 
(Vide  p.  60.) 

The  dysenteric  process  occurs  in  its  exquisite  and  primary  form  in  the 
colon  only,  with  the  exception  of  the  mucous  membrane  of  the  female 
sexual  organs,  where  it  affects  the  uterine  mucous  membrane  in  the  shape 
of  the  puerperal  disease. 

The  dysenteric  process  offers  the  greatest  analogy  to  the  corrosion  of 
the  mucous  membrane  produced  by  a  caustic  acid.  The  consequent 
destruction  of  the  tissues,  as  well  as  the  phenomena  of  reaction,  present 
throughout  a  close  resemblance  in  both  cases,  and  the  stricture  produced 
in  the  oesophagus  has  no  analogue  but  that  resulting  in  the  colon  from 
the  dysenteric  affection. 

AVe  have  found  a  further  analogy  with  the  dysenteric  process  in  the 
erodent  effect  produced  upon  the  mucous  membrane  of  the  oesophagus 
by  the  gastric  juice  in  scirrhous  stenosis  of  the  pylorus. 

Appendix. —  The  Non-typhous  Intumescence  of  the  Follicles  and  Villi 

of  the  Intestines. 

Although  the  intumescence  of  the  intestinal  follicles  occurring  in 
various  morbid  conditions  is  not  the  consequence  of  palpable  inflammatory 
action,  it  may  yet  be  fairly  considered  at  this  place,  as  it  commonly  ap- 
pears to  result  from  the  relation  of  certain  general  morbid  states  to  the 
follicular  apparatus. 

AYe  find  that  the  patches  of  Peyer  in  the  small  intestine,  the  solitary 
follicles  of  the  small  and  large  intestine,  and  the  follicles  of  Lieberklihn, 
in  the  small  intestine,  may  be  affected  in  this  manner.  The  affection  is 
observed : 

1.  In  substantive  affections  of  the  intestinal  mucous  membrane,  as  in 
diarrhoea,  and  particularly  when  occurring  in  children,  in  whom  it  is 
marked  by  more  or  less  vascularity  and  congestion,  but  frequently  also 
by  an  anaemic  condition  of  the  parts.  In  the  diarrhoea  of  children  and 
young  persons  we  find,  besides  an  enlargement  of  the  solitary  and  of 
Peyer's  glands,  a  dilatation  of  Lieberkuhn's  follicles ;  a  grayish-white 
creamy  matter  accumulates  in  their  interior,  which  produces  a  whitish 
punctiform  appearance  in  the  intestinal  mucous  membrane,  or,  in  trans- 
mitted light,  gives  rise  to  so  many  opacities. 


78  ABNORMITIES    OF    THE 

2.  The  affection  occurs  most  frequently  as  a  reflex  of  constitutional 
disease  :  under  these  circumstances,  the  swellings  of  the  solitary  and  of 
Peyer's  follicles  are  found  principally  in  the  colon'  in  typhoid  gastro- 
enteric  fevers,  as  an  imperfectly-developed  secondary  typhous  eruption 
in  almost  all  the  exanthemata,  but  especially  in  scarlet  fever,  variola, 
and  erysipelas  ;  in  acute  rheumatism  and  gout ;  in  croup ;  in  suppurative 
and  gangrenous  disease  ;  in  febrile  affections  of  the  lymphatic  glands  in 
scrofulous  individuals  ;  in  hydrocephalic  fever ;  in  a  marked  form  in  com- 
mon Asiatic  cholera;    and   lastly,  in  acute   convulsions,   trismus,   and 
tetanus.     The  villi  are  generally  also  much  swollen,  but  we  invariably 
find  the  mesenteric  glands  in  a  state  of  tumefaction. 

Swelling  of  the  follicles  is  the  consequence  of  a  deposition  of  a  grayish- 
red,  dull-white,  or  yellowish  substance,  of  a  lardaceous  or  creamy  and 
glutinous  consistence  in  the  cavity  of  the  follicle,  accompanied  by  an 
analogous  infiltration  of  its  parietes  ;  thus  the  follicle  and  the  deposit  not 
unfrequently  appear  to  constitute  a  homogeneous  body,  to  which  the 
term  "  granulations  of  the  intestinal  mucous  membrane"  has  been  applied. 
This  follicular  affection  differs  from  that  occurring  in  typhus  in  everything 
that  characterizes  the  latter,  and  especially  in  reference  to  the  metamor- 
phosis of  the  typhous  follicle. 

According  to  the  predisposing  constitutional  causes,  the  affection  we 
are  treating  of  is  more  or  less  acute  and  transitory  ;  the  deposit,  the  folli- 
cular tissue,  and  the  mucous  membrane  in  very  rare  cases  fuse  into  a 
small  shallow  ulcer ;  induration  and  a  "further  development  occasionally 
take  place,  and  the  mucous  membrane  being  pushed  forwards,  a  species 
of  polypoid  pediculated  growth  is  formed. 

3.  Grangrene  of  the  mucous  membrane. — We  have  had  occasion  to 
examine  the  ulcerative  process  consequent  upon  inflammation  in  a  variety 
of  forms,  and  any  further  investigation  of  the  subject  were  superfluous. 
We  pass  at  once  to  gangrene  of  the  mucous  membrane,  although  we  must 
observe  that  it  rarely  is  a  direct  consequence  of  inflammation. 

Gangrene  of  the  mucous  membrane  is  brought  on  by  compression  and 
traction,  and  is  generally  accompanied  by  gangrene  of  the  other  intestinal 
coats,  as  in  incarcerated  hernia  at  the  point  of  strangulation,  or  in  con- 
sequence of  excessive  dilatation  of  a  portion  of  intestine  above  a  stricture, 
at  various  scattered  points ;  it  may  occur  in  large  patches  in  consequence 
of  mechanical  hypersemia  brought  on  by  incarceration,  or  of  passive  con- 
gestion induced  by  paralysis  ;  it  may  take  place  in  the  shape  of  a  circum- 
scribed slough  of  the  mucous  membrane  consequent  upon  inflammatory 
action  (gangrenous  inflammation  strictly  so  called),  in  which  the  peculiar 
anomalous  state  of  the  blood  and  the  peculiar  nature  of  the  product,  are 
the  cause  of  mortification.  To  this  head  belong  the  sloughs  of  the  intes- 
tinal mucous  membrane,  which  occur  with  symptoms  of  general  adynamia 
and  putrescence,  in  acute  dyscrasia  of  the  blood,  in  purulent  and  ichorous 
infection  of  the  blood,  under  the  form  of  degenerated  typhus,  cholera 
typhus,  &c. 

After  the  slough  has  become  detached  there  is  a  loss  of  substance  in 
the  mucous  membrane  which  demands  some  attention,  as  it  may  be  con- 
founded with  an  intestinal  ulcer ;  the  diagnosis  is  established  by  the 


INTESTINAL    CANAL.  79 

existence  of  an  external  or  internal  cause  of  gangrene,  or  by  a  corre- 
spondence, in  seat  and  form,  between  the  latter  and  the  external  influence 
(compression,  traction) ;  again,  the  slough  of  gangrenous  inflammation  is 
distinguished  by  its  oblong,  striated  form,  and  very  varying  seat,  by  its 
defined  contour,  and  by  the  absence  of  morbid  growth  at  the  edge,  at  the 
base,  as  well  as  in  the  circumference  of  the  eroded  part. 

4.  Inflammation  of  the  submucous  cellular  tissue. — In  several  of  the 
processes  we  have  hitherto  considered,  we  have  had  occasion  to  notice 
the  various  modes  and  degrees  in  which  the  submucous  cellular  tissue  is 
involved  in  disease  of  the  mucous  membrane.     An  isolated  inflammation 
of  the  submucous  cellular  tissue  is  very  rare,  and  when  it  does  occur  it 
is  commonly  metastatic  and  terminates  in  suppuration.     It  takes  place  in 
the  shape  of  distinct  foci  of  varying  extent,  which  either  give  rise  to  per- 
foration of  the  mucous  membrane,  or  advance  towards  the  peritoneum, 
and  here  produce  peritonitis ;  or  in  certain  portions  of  the  intestine,  as 
in  the  caecum,  colon  ascendens,  and  rectum,  produce  extensive  suppuration 
of  the  cellular  tissue. 

5.  Softening  of  the  intestinal  canal. — We  may  pass  over  the  soften- 
ing of  the  intestinal  mucous  membrane  which  we  have  described  when 
treating  of  the  Exudative  Processes  and  Dysentery,  as  converting  the 
tissue  into  a  pulp,  which,  in  proportion  to  the  state  of  vascular  action, 
and  to  the  quality  of  the  exuding  matters,  is  either  easily  removable  or 
is  spontaneously  detached.     We  have  here  to  allude  to  the  gelatinous 
ramollissement  of  the    intestinal  mucous    membrane,   which  offers  an 
analogue  to  the  gelatinous  softening  of  the  gastric  mucous  membrane.   It 
is  of  much  rarer  occurrence  than  the  latter,  though  like  this,  it  affects 
the  small  intestine  as  a  complication  of  cerebral  disease,  of  acidity  in  the 
primse  vise,  of  extreme  general  collapse,  atrophy  of  the  muscular  tissue,  and 
anaemia  of  the  intestine ;  it  involves  the  external  coats  of  the  intestine, 
converts  them  into   a  homogeneous,  grayish-red,  transparent,  and  de- 
liquescent gelatine,  and  leads  to  spontaneous   perforation.      We  also 
advert  to  the   analogue  of  black  softening  of  the  stomach,  which  occa- 
sionally, though  much  more  rarely,  attacks  the  intestine.     It  occurs 
under  the  same  conditions,  and  mainly  affects  the  mucous  membrane  of 
the  caecum,  and  in  this  case  occurs,   like  gelatinous  softening,   on  the 
cellular  base  of  the  typhous  ulcer. 

6.  Morbid  growths  in  the  intestinal  canal. — Under  this  head  we  con- 
sider lipoma,   the  formation  of  an  anomalous,  serous,  and  fibre-serous 
tissue,   fibrous   and   fibro-cartilaginous    tissue,  calcareous    concretions, 
erectile  tissue,  tubercle,  and  scirrhus. 

a.  Lipoma  occurs  of  various  size  in  the  shape  of  lobulated  accumula- 
tions of  fat  in  the  submucous  cellular  tissue.  It  forms  rounded  tumors 
which  are  invested  by  mucous  membrane,  project  into  the  intestinal 
canal,  and  are  sessile,  or  pediculated :  in  the  latter  case  they  push  the 
mucous  membrane  before  them  in  the  course  of  their  development,  and 
become  suspended  by  a  pedicle  of  mucous  membrane.  Although  pre- 


80  ABNORMITIES    OF    THE 

senting  a  polypoid  shape,  they  must  be  carefully  distinguished  from  true 
polypus. 

b.  Anomalous  serous  and  fibro-serous  tissue  occurs  as  a  temporary  or 
permanent  substitute  of  loss  of  tissue  in  the  mucous  membrane,  and  in 
very  rare  cases  in  the  shape  of  serous  and  fibro-serous  cysts  between  the 
intestinal  coats. 

c.  Fibrous  and  fibro-cartilaginous  tissue  is  found  in  the  submucous 
cellular  tissue  of  the  stomach,  and  less  frequently,  of  the  oesophagus  ;  it 
assumes  the  shape  of  the  rounded  or  oval,  flattened  concretions ;  of  a 
bluish-white  color,  and  elastic  and  firm  consistence,  which  we  have  de- 
scribed above.     They  do  not  attain  a  greater  size  than  that  of  a  lentil 
or  pea,  and  are  freely  movable  under  the  mucous  membrane. 

d.  Chalky  concretions  more  or  less  resembling  bone,  though  destitute 
of  its  peculiar  organization  (so-called  ossifications),  occur  very  rarely  in 
the  intestinal  canal.     If  we  sum  up  the  results  of  the  observations  made 
in  reference  to  this  point,  taken  in  connection  with  our  incidental  remarks 
when  considering  the  diseases  of  the  peritoneum,  we  arrive  at  the  follow- 
ing deductions  : 

a.  The  concretions  occur  as  lamellae  or  delicate  cords  in  the  sero- 
fibrous  tissue  which  is  formed  supplementary  to  a  loss  of  mucous  tissue ; 

/9.  As  ossification  of  the  fibroid  tissue  occurring  in  the  submucous  and 
subserous  cellular  layers ; 

f.  As  a  loose  chalky  concretion  or  indurated  calcareous  pus  between 
the  intestinal  coats  in  sinuses  accompanying  catarrhal  intestinal  phthisis ; 

d.  As  calcareous  tubercle  of  the  intestinal  mucous  membrane  or  the 
peritoneum  ; 

e.  As  ossification  of  peritoneal  exudation  on  the  intestine. 

e.  Erectile  tissue  occurs  as  a  pediculated  polypus  (mucous  or  cellular 
polypus),  or  in  the  shape  of  large,  broad,  sessile  tumors,  chiefly  as  a 
consequence  of  catarrh  in  the  colon  and  rectum.  It  may  in  this  case 
also  be  the  seat  of  medullary  carcinomatous  infiltration. 

/.  Tubercle. — The  presence  of  tubercle  in  the  tissue  of  the  intestinal 
mucous  membrane,  and  by  extension,  in  the  deeper-seated  coats,  con- 
stitutes a  most  important  disease — tuberculosis  of  the  intestine  in  the 
wide,  tuberculosis  of  the  intestinal  mucous  membrane  in  the  narrower 
sense.  It  may  proceed  to  ulcerative  destruction,  and  this  establishes 
genuine  intestinal  phthisis. 

Amongst  ourselves  this  affection  rarely  occurs  in  the  idiopathic  form, 
except  during  the  first  years  of  life.  It  is  commonly  the  consequence  of 
pulmonary  tuberculosis,  and  in  the  majority  of  cases,  takes  place  after 
the  latter  has  attained  the  suppurative  stage  (pulmonary  phthisis),  and 
the  general  tubercular  cachexia  has  become  fully  developed. 

The  course  it  runs  is  frequently  chronic,  but  much  oftener  acute  :  the 
latter  is  more  particularly  the  case  when  it  follows  the  tumultuous  fusion 
of  numerous  pulmonary  tubercles.  The  tubercular  deposit  offers  corre- 
sponding varieties  in  reference  to  its  original  form,  its  seat,  and  its 
metamorphosis. 

In  the  chronic  affection  we  find  the  mucous  membrane,  and  the  adja- 
cent layer  of  submucous  cellular  tissue,  to  be  the  original  seat  of  the 
tubercular  deposit ;  there  is  no  perceptible  inflammatory  action,  and  the 


INTESTINAL    CANAL.  81 

disease  appears  in  the  shape  of  the  gray,  transparent,  tubercular  granu- 
lation, which  softens  at  its  centre,  and  is  gradually  converted  from 
within  outwards,  into  the  yellow  cheesy  tubercle.  It  seems  blended  with 
the  mucous  membrane,  and  projects  into  the  intestinal  cavity  in  the 
shape  of  a  sessile,  hard  nodule. 

When  the  local  appearance  of  tubercle  takes  place  in  the  acute  form, 
there  is  considerable  inflammatory  action.  The  deposit  is  effected  simi- 
larly to  that  occurring  in  the  pulmonary  cells  ;  in  the  first  instance  it  is 
deposited  in  the  cavity  of  Peyer's  glands,  then  into  the  solitary  follicles, 
and  lastly,  in  every  other  part  of  the  intestinal  mucous  tissue ;  it  appears 
in  large  masses,  and  in  the  shape  of  yellow,  cheesy  matter,  which 
speedily  undergoes  a  purulent  transformation.  The  surrounding  tissue 
is  found  extensively  congested,  reddened  and  turgid ;  and  when  the  de- 
posit is  excessive,  the  mucous  membrane  of  an  entire  coil  may  be  in  a 
state  of  congestion  and  irritation.  In  this  case  tubercular  tumors,  either 
scattered  over  the  surface  of  the  intestine  or  more  or  less  accumulated, 
are  found  occupying  Peyer's  patches,  offering  considerable  projections 
and  distinguishable  through  the  mucous  membrane  by  their  yellow  tinge. 

Tubercular  deposit  in  the  intestinal  mucous  membrane,  being  the  re- 
sult of  a  fully-developed  tubercular  cachexia,  commonly  advances  rapidly 
to  softening,  and  this  process  is  effected  with  peculiar  violence  in  the 
second  variety.  The  investing  mucous  membrane  gives  way  at  its  most 
elevated  point,  and  as  the  orifice  enlarges,  the  suppurating  tubercular 
matter  escapes. 

A  cup-shaped  ulcer,  of  the  size  of  a  millet  seed  or  a  pea  (the  primary 
tubercular  ulcer)  results  ;  its  margin  is  ,firmly  attached,  rounded  and  in- 
durated, and  of  a  pale  or  red  color  in  proportion  to  the  reaction  that 
occurs  in  the  surrounding  tissue ;  its  base  is  either  formed  by  the  con- 
densed submucous  cellular  layer,  or  by  the  granulated  texture  of  the 
parietes  of  the  dilated  follicle.  It  is  only  in  very  rare  cases  that  the 
tubercle  fuses  under  the  mucous  membrane  without  giving  rise  to  per- 
foration ;  it  then  forms  at  the  expense  of  an  inclosed  abscess,  which 
enlarges  the  submucous  cellular  tissue  (vomica  submucosa). 

The  increase  of  the  ulcer  takes  place  with  more  or  less  rapidity,  it 
loses  its  original  form,  but  only  to  exchange  it  for  a  more  characteristic 
secondary  one. 

The  increase  is  effected  by  fusion  of  the  tubercular  infiltration  of  the 
margin  of  the  ulcer,  and  by  concurrent  suppuration  of  the  tissue.  In 
the  first  instance,  the  small  adjoining  ulcers  coalesce  into  one  of  larger 
size ;  the  common  base  presents  sinuous  projections  of  the  common 
margin  of  mucous  tissue,  ridges  of  mucous  membrane  may  be  seen  travers- 
ing it  in  various  directions,  or  even  solitary  insular  remnants  of  this 
tissue  are  found  upon  it. 

If  this  process  has  occurred,  as  it  does  in  acute  intestinal  tuberculosis, 
in  one  of  Peyer's  patches,  the  ulcer  may,  on  account  of  the  elliptic  form 
prescribed  by  the  shape  of  the  glandular  apparatus,  be  mistaken  for  a 
typhous  ulcer,  but  we  shall  immediately  point  out  that  the  peculiar  re- 
lations of  the  margin  and  the  base  afford  a  satisfactory  clue  to  the  diag- 
nosis. 

VOL.  II.  6 


82  ABNORMITIES    OF    THE 

The  ulcer,  which  is  formed  by  a  coalition  of  other  smaller  ulcers, 
enlarges  in  the  same  manner  as  the  original  solitary  ulcer,  in  the  direc- 
tion of  the  intestinal  circumference,  and  at  last  presents  a  zone  of 
varying  width  and  uniformity.  Its  margin  is  sinuous  or  dentated,  in- 
verted and  tumid,  and  is  formed  by  mucous  membrane  of  a  light  red 
color;  from  the  latter  being  infiltrated  with  a  transparent  gelatinous 
substance,  an  analogy  is  offered  with  the  gelatinous  infiltration  occurring 
in  the  vicinity  of  tubercular  pulmonary  abscesses.  The  base  is  formed 
by  callous  cellular  tissue  of  a  dirty  white  color,  underneath  which  the 
remaining  intestinal  layers  are  found  similarly  condensed  and  tumefied. 

Both  in  the  marginal  tissue  and  at  the  base  we  find  a  deposition  of 
gray,  or  more  commonly  of  soft,  yellow,  tubercular  matter.  The  ulcer 
presents  a  very  peculiar  appearance,  on  account  of  the  remnants  cf  mu- 
cous membrane  seen  on  its  base.  These  adopt  the  characters  of  the 
margin,  and  become  infiltrated  with  gelatinous  matter,  so  as  to  form 
crispated,  transparent,  condylomatous  excrescences  of  a  light-red  color. 

In  the  same  manner  as  the  tubercular  ulcer  extends  laterally,  it  may 
advance  in  the  opposite  direction,  and  thus  giving  rise  to  perforation, 
cause  sudden  death.  Secondary  deposition  of  tubercular  matter  may 
equally  take  place  in  the  callous  cellular  tissue  of  the  base,  and  as  it 
fuses  at  this  point,  in  the  muscular  and  subserous  layers  also.  The  peri- 
toneum may  become  perforated  in  consequence  of  tubercular  suppuration 
being  established  in  it,  or  in  consequence  of  mortification  induced  by  the 
approach  of  an  abscess.  It  follows  that  the  tubercular  ulcer  perforates 
the  intestinal  parietes  without  losing  its  original  character,  inasmuch  as 
the  progress  of  the  tubercular  affection  is  not  arrested  by  an  isolating 
tissue  ;  in  this  it  differs  from  the  typhous  ulcer,  which  does  not  perforate 
the  intestine  in  its  original  form,  but  affects  the  parts  beyond  the  sub- 
mucous  cellular  tissue  in  its  degenerated  character. 

At  an  earlier  or  later  period  we  find  moderate  inflammation  attacking 
points  of  the  peritoneum  which  correspond  in  position  to  the  intestinal 
ulcer ;  a  fibrinous  exudation  results,  which  is  entirely,  or  in  part,  con- 
verted into  tubercle ;  in  the  latter  case  it  is  partly  converted  into  cel- 
lular tissue.  By  the  intervention  of  this  new  product  an  adhesion  is 
often  effected  at  the  point  of  ulceration,  between  the  intestine  and  a 
neighboring  organ,  e.  g.  the  bladder,  the  omentum,  and  thus  a  more  or 
less  substantial  impediment  is  offered  to  the  free  discharge  of  the  intes- 
tinal contents  into  the  peritoneal  cavity  on  the  occurrence  of  perforation. 

The  inesenteric  glands,  lying  in  the  vicinity  of  the  affected  portion  of 
the  intestine,  are  variously  enlarged :  in  the  primary  intestinal  tuber- 
culosis of  children  they  frequently  attain  the  size  of  a  walnut  or  hen's 
egg ;  they  appear  tuberculated  and  pale,  and  present  a  deposition  of 
grayish,  medullary,  and  hard,  or  of  yellow,  grumous,  and  deliquescent, 
tubercular  matter. 

The  small  intestine  is  the  common  seat  of  intestinal  tuberculosis, 
and  in  most  cases  the  disease  is  limited  to  this  part ;  still  it  often  passes 
on  to  the  colon  and  descends  to  the  rectum,  or  it  ascends  into  the  jeju- 
num, and  in  very  rare  cases  mounts  to  fhe  duodenum  and  the  stomach. 
Sometimes  it  is  much  advanced  in  the  colon  and  then  appears  to  have 


INTESTINAL    CANAL.  83 

been  first  developed  at  this  point  and  subsequently  to  have  extended 
to  the  small  intestine. 

We  may  gather  from  the  circumstances  accompanying  intestinal  tuber- 
culosis, that  the  further  it  has  advanced  the  less  a  cure  is  to  be  hoped 
for.  Still  in  the  same  manner  as  in  the  tubercular  abscesses  of  the  lungs, 
we  sometimes  obcerve  a  healing  process  established  in  a  few  among  a 
large  number  of  ulcers.  It  takes  place  in  the  following  manner. 

The  first  indispensable  condition  is  the  cessation  of  all  secondary  tuber- 
cular infiltration  at  the  margin  or  base  of  the  ulcer ;  the  callous  base  is 
then  condensed  into  a  fibro-medullary  cord,  and  the  edges  of  the  ulcer 
approach  one  another.  This  process  sometimes  advances  so  far,  that 
the  dentated  edges  almost  touch,  and  between  them  a  whitish,  cal- 
lous cord  may  be  observed.  Occasionally,  the  edges  are  soldered  to- 
gether over  the  callosity,  yet  so  as  to  leave  a  fissure  at  one  end  of  the 
ulcer.  In  very  rare  cases  an  entire  consolidation  is  effected. 

In  consequence  of  the  contraction  of  the  ulcer,  a  cicatrix  forms  on  the 
surface  of  the  intestine,  which  presents  a  more  or  less  elevated  tumid 
ridge  on  the  internal  surface  of  the  intestine.  If  the  ulcer  was  of  con- 
siderable size,  or  if  it  encircled  the  entire  intestine,  a  callous  annular 
ridge  remains,  which  diminishes  the  calibre  of  the  intestine,  and  when 
viewed  from  without,  occasionally  gives  rise  to  an  appearance  of  inva- 
gination. 

Thus  the  cure  of  a  tubercular  intestinal  ulcer  is  always  accompanied 
by  a  diminution  of  the  intestinal  calibre. 

g.  Scirrhus,  carcinoma  of  the  intestine. — The  carcinomatous  affections 
of  the  intestine,  occur  in  the  three  forms  of  fibrous,  areolar,  and  medul- 
lary cancer,  with  and  without  the  formation  of  pigment :  two  of  these  or 
all  three,  may  be  combined  with  one  another,  from  their  first  origin  or 
consecutively.  The  areolar  form,  however  is,  at  least  with  us,  of  very 
rare  occurrence. 

The  colon  is  almost  exclusively  the  seat  of  cancerous  degeneration,  but 
there  is  a  gradation  in  the  proclivity  of  its  different  sections  to  the  affec- 
tion. The  rectum  is  most  frequently  attacked,  in  second  order  the  sig- 
moid  flexure,  and  the  remaining  portion  of  the  colon  but  rarely.  The 
small  intestine  is  scarcely  ever  the  primary  seat  of  cancer  ;  it  is  almost 
always  involved  secondarily  after  adhesions  have  been  effected  with  a 
cancerous  portion  of  the  colon  by  means  of  peritoneal  exudation.  Me- 
dullary carcinomatous  cachexia,  which  is  frequently  acute  and  very  exten- 
sive, forms  an  exception,  inasmuch  as  it  gives  rise  to  a  medullary,  white 
or  colored  infiltration  of  the  mucous  membrane  of  the  small  intestine  and 
its  submucous  cellular  tissue  in  the  patches  of  Peyer.  If  we  except 
this  case,  carcinoma  occurs  as  a  primary  affection  of  the  intestine  in  three 
forms : 

Firstly,  In  the  mucous  membrane,  as  carcinomatous  infiltration  of 
the  erectile  tissue,  into  which  the  former  has  been  previously  converted 
— fungus ; 

Secondly,  More  frequently  in  the  submucous  cellular  tissue,  as  round 
nodulated  accumulations  ; 

Thirdly,  Most  commonly  as  an  annular  deposit  of  the  cancerous  tissue 
in  the  submucous  cellular  layer. 


84  ABNORMITIES    OF    THE 

When  the  intestine  is  secondarily  involved,  it  is  attacked  laterally, 
and  the  disease  commonly  proceeds  from  the  lymphatic  glands  of  the 
mesentery,  or  from  those  of  the  lumbar  plexus. 

A  distinction  of  the  two  latter  forms  is  of  importance,  in  reference  to 
the  observations  that  we  are  about  to  make. 

Here  also,  carcinoma  presents  the  well-known  stages  of  crudity  and 
metamorphosis ;  and  we  merely  direct  attention  to  this  again,  because  a 
consideration  of  the  fact  is  absolutely  necessary  for  a  complete  exposi- 
tion of  cancerous  intestinal  stricture,  which,  next  to  cancer  itself  is  of 
extreme  interest. 

Cancerous  stricture  of  the  intestine1  (Enterostenosis  scirrhosa,  cancer- 
osa)  is  the  most  common  variety  of  stricture  that  results  from  altera- 
tions in  the  intestinal  coats,  and  at  the  same  time  the  one  that  advances 
to  the  highest  degree ;  it  also  offers  the  first  elements  for  a  rational  theory 
of  ileus. 

We  have  already  alluded  to  the  two  main  forms  in  which  cancer  affects 
the  intestine  :  it  is  either  a  narrow  annular  tumor  surrounding  the  intes- 
tine, the  primary  form,  which  gives  rise  to  annular  stricture  ;  or  the  in- 
testine is  secondarily  affected  by  a  propagation  of  the  disease  from  neigh- 
boring organs;  in  this  case  one  side  only  may  be  involved  to  a  consider- 
able extent.  In  the  latter  case,  however,  the  cancerous  degeneration 
may  gradually  extend  over  the  entire  circumference  of  the  intestine,  as 
in  the  former  the  original  annular  stricture  may  extend  upwards  or  down- 
wards over  a  larger  portion  of  intestine!1 

The  annular  stricture  is  commonly  the  most  important ;  if  the  morbid 
growth  continues  in  the  crude  stage,  the  calibre  of  the  intestine  may  be 
reduced  to  the  size  of  the  little  finger,  a  goose's  or  crow's  quill.  The 
passage  of  the  intestine  is  frequently  much  interfered  with  in  the  lateral 
degeneration  by  protrusion  of  the  morbid  growth,  but  there  is  generally 
a  corresponding  dilatation  of  the  normal  portion  of  the  parietes,  and  the 
width  of  the  tube  is  thus  not  unfrequently  found  increased,  even  after  the 
morbid  growth  has  enveloped  the  entire  circumference  of  the  intestine. 
Although  the  former  is  by  far  the  most  dangerous,  and  soon  proves  fatal 
by  ileus,  this  also  follows  sooner  or  later  in  the  second  case,  notwithstand- 
ing the  existing  dilatation. 

The  metamorphosis  of  intestinal  cancer  is  of  importance  in  reference 
to  the  stricture,  both  in  its  first  development  and  in  its  further  progress ; 
it  may  render  the  stricture  much  more  dangerous,  or  may  lead  to  a  cer- 
tain improvement  in  the  symptoms.  The  turgescence  that  takes  place  in 
the  morbid  growth  at  the  commencement  of  the  change,  and  the  fungous 
excrescences  that  arise  on  the  surface  of  the  intestine  during  its  progress, 
may  render  the  stricture  narrower,  and  even  induce  perfect  occlusion  of 
the  intestine.  On  the  other  hand,  the  contraction  may  be  relieved  by 
sloughing  of  the  softened  morbid  growth,  and  imminent  ileus  thus  be 
postponed.  The  intestinal  disease  may,  unless  death  ensue,  as  it  often 
does  from  exhaustion,  be  subsequently  ameliorated  in  various  ways. 
After  destruction  of  the  morbid  growth,  an  ichorous  cavity  is  left,  into 
which  the  descending  contents  of  the  intestine  pass  and  stagnate;  this 

1  Oestr.  Jahrb.  xviii.  1. 


INTESTINAL     CANAL.  85 

condition  is  sometimes  borne  for  a  considerable  period,  provided  there 
is  a  sufficient  discharge  downwards.  In  other  cases  ulcerative  perfora- 
tions may  establish  one  or  more  communications  between  the  portions 
of  intestine  lying  above  and  below  the  stricture,  or  ulcerative  destruction 
may  take  place  in  a  different  direction,  and  give  rise  to  artificial  (vicari- 
ous) anus  ;  thus  affording  a  hint  as  to  the  mode  of  cure  to  be  adopted  by 
the  medical  man. 

The  degenerated  and  strictured  portion  of  the  intestine  may  remain 
unattached,  or  become  fixed.  The  primary  degeneration  of  the  intestine, 
exhibited  in  annular  stricture,  is  commonly  unattached,  and  it  then,  in 
proportion  as  the  diseased  mass  increases,  sinks  to  a  lower  region  of  the 
abdominal  cavity.  This  may,  in  the  same  manner  as  the  scirrhous 
pylorus,  when  it  has  descended  to  the  umbilical  or  hypogastric  regions, 
give  rise  to  an  error  of  diagnosis.  The  dislocation  is  particularly  liable 
to  present  an  obstacle  to  the  passage  of  the  intestinal  contents,  if  the 
contracted  portion  is  bent  at  an  acute  angle,  as  occurs  in  the  descent 
of  strictured  portions  of  the  transverse  colon,  or  of  the  flexures  of  the 
colon. 

The  diseased  portion  of  intestine  may  be  fixed,  as  is  the  case  in  the 
secondary  lateral  degeneration  of  the  intestine  from  its  commencement ; 
the  annular  stricture  may  become  attached  in  the  same,  or  in  a  different 
manner.  In  the  former  case  the  intestine  is  either  directly  connected 
with  the  large  lobulated  morbid  growths  that  extend  to  the  glands  of 
the  lumbar  plexus,  or  even  to  the  ligamentous  appendages  and  the  peri- 
osteum of  the  vertebne  (Lobstein's  retroperitoneal  growths),  or  it  is  at- 
tached to  them  by  the  intervention  of  a  cord  or  peduncle  which  passes 
through  the  mesentery.  In  consequence  of  the  partial  contraction  of 
the  tissues,  and  especially  of  the  intestinal  coats,  and  of  the  unequal 
distribution  of  the  morbid  growth,  the  degenerated  portion  of  the  tube 
is  more  or  less  inflected. 

The  annular  stricture,  which  in  the  first  instance  is  unattached,  may, 
as  the  cancer  advances,  become  fixed  in  a  similar  manner  at  the  point 
of  its  original  development,  or  at  different  parts  at  a  distance  from  this 
point,  either  by  cellular  tissue,  or  by  a  fusion  of  the  carcinomatous 
tissues.  The  propulsion  of  the  intestinal  contents  will,  in  that  case,  be 
impeded  to  a  greater  degree  than  in  simple  dislocation,  and  the  more 
so,  the  greater  the  dislocation  itself,  the  more  acute  the  angle  of  inflec- 
tion, and  the  more  firm  the  adhesions  are. 

The  intestine  lying  above  the  diseased  portion  is  found  affected  to  a 
various  extent,  and  commonly  in  proportion  to  the  amount  of  contrac- 
tion, by  active  dilatation,  i.  e.,  dilatation  accompanied  by  hypertrophy 
of  the  muscular  coat.  The  parietes  of  this  section  of  the  intestine  are 
occasionally  found  very  much  thickened  and  indurated ;  the  muscular 
coat  presents  a  yellow  discoloration  and  is  friable,  the  cellular  layers 
are  infiltrated  with  a  gelatinous  medullary  substance,  the  mucous  mem- 
brane is  thinned  and  resembles  a  serous  membrane,  and  the  contents  of 
the  intestine  accumulate  to  a  considerable  extent  above  the  affected 
point.  The  portion  of  intestine  which  lies  below  the  cancerous  mass  is 
more  or  less  permanently  contracted  and  empty. 

In  considering  the  metamorphosis  of  intestinal  scirrhus,  we  have  ad- 


86  ABNORMITIES    OF    THE 

verted  to  its  terminations  ;  it  commonly  ends  fatally  with  symptoms  of 
intestinal  inflammation  and  ileus. 

Cancerous  ulceration,  more  frequently  than  any  other  variety  of  ul- 
ceration, gives  rise  to  communications  between  the  affected  portion  of 
intestine  and  neighboring  cavities  and  passages,  and  more  especially 
with  the  rectum. 

Intestinal  carcinoma  often  occurs  in  the  isolated  form,  but  it  is  not 
unfrequently  complicated  with  cancer  of  the  stomach,  the  liver,  the 
lymphatic  glands,  and  the  bones,  with  osteomalacia,  and  universal  can- 
cerous cachexia. 

There  are  certain  ulcers  which  occur  only  in  the  large  intestine,  and 
especially  in  the  sigmoid  flexure  and  the  rectum,  and  are  nearly  allied 
to  cancer,  and  particularly  to  cutaneous  cancer.  They  are  generally 
solitary,  but  there  may  be  two,  three,  or  four  at  a  time.  They  inva- 
riably give  rise  to  intense  pain,  and  appear  etiologically  connected  with 
an  abuse  of  ardent  spirits.  Although  in  many  respects  analogous  to 
the  ulcers  hitherto  considered,  they  offer  distinctive  characters.  They 
are  invariably  zonular  and  have  a  callous  base,  upon  which  occasionally 
a  discolored,  brownish,  grumous  discharge  is  visible,  and  they  are  sur- 
rounded, by  a  thick,  tumid,  spongy,  carneous,  and  irregularly-sinuous 
margin  of  mucous  membrane.  They  generally  cause  a  diminution  of 
the  capacity  of  the  intestine,  though  not  to  any  considerable  degree.  A 
further  investigation  into  their  nature  $till  remains  a  desideratum. 


7.  Theory  of  the  ileus  produced  by  cancerous  degeneration  of  the  in- 
testine.— Independent  of  the  degree  of  stricture,  the  degenerated  portion 
of  the  intestine,  owing  to  the  adventitious  growth  deposited  in  the  sub- 
mucous  tissue,  and  still  more  from  the  consequent  disorganization  of  the 
muscular  coat,  is  in  a  completely  passive  condition.  The  propulsion  of 
the  faeces  through  this  portion  is  therefore  effected  by  the  muscular 
activity  of  the  higher  part  of  the  intestine,  even  when  the  lateral  posi- 
tion of  the  disease  allows  of  dilatation.  The  more  considerable  the 
stricture,  or  the  more  extensive  the  growth,  and  the  more  copious  the 
feculent  accumulation,  the  more  will  this  activity  be  called  into  play. 

The  contents  of  the  intestine  necessarily  stagnate  and  accumulate  in 
that  portion  which  lies  immediately  above  the  diseased  point,  and  dilate 
it.  If  the  dilatation  is  effected  suddenly,  paralysis  at  once  ensues; 
otherwise  the  accumulated  masses,  a  certain  portion  of  which  are  only 
propelled  through  the  degenerated  section  of  the  intestine,  give  rise  to 
reaction,  hypertrophy  of  the  membranes  follows,  and  as  these  influences 
increase,  gradual  exhaustion  and  paralysis  result.  This  paralyzed  por- 
tion of  intestine  is  the  proximate  cause  of  the  supervening  ileus.  As 
soon  as  the  faeces  have  accumulated  within  it  to  such  an  extent  as  to 
reach  the  adjacent  sound  portion  of  intestine,  the  latter  undertakes  their 
discharge.  Its  capability  of  effecting  this  will  diminish  in  proportion 
to  the  amount  of  accumulation,  and  to  the  contraction  of  the  stricture. 
The  consequence  is,  that  the  peristaltic  action  is  reversed,  and  that  the 
antiperistaltic  movement  conveys  the  intestinal  contents  to  the  stomach, 
from  which  they  are  ejected  by  vomiting. 

The  coexistent  intestinal  inflammation,  which  commonly  occurs  as 
general  peritonitis,  also  has  a  share  in  the  process.  It  commences  at 


INTESTINAL    CANAL.  87 

that  point  immediately  above  the  stricture,  which  has  become  most  di- 
lated by  the  accumulated  contents,  and  it  is  there  most  intense.  This 
portion  of  intestine  presents  a  dark-blue  or  blackish-red  discoloration, 
with  a  tinge  of  brown  or  green ;  its  coats  are  infiltrated  with  blood  ;  the 
peritoneal  investment,  which  is  covered  with  a  dirty-green  or  brownish 
exudation,  is  easily  detached ;  the  muscular  coat  is  discolored  and  friable ; 
the  mucous  membrane,  owing  to  its  distension,  is  devoid  of  plicae,  villi, 
or  follicles ;  dark-red,  distended  at  some  parts  with  coagula,  and  sloughy. 
Sometimes  all  the  intestinal  coats  are  perforated  at  these  points,  and 
there  is  consequently  an  extravasation  of  the  intestinal  contents  into  the 
abdominal  cavity. 

The  inflammation  extends  from  this  portion  of  the  intestine  upwards, 
and  is  followed,  pari  passu,  by  paralysis.  It  passes  from  the  intestine 
to  the  mesenteries,  to  the  omentum,  and  to  the  parietal  laminae  of  the 
peritoneum. 

In  some  cases  the  inflammation  is  the  result  of  irritation  existing  in 
the  morbid  product,  which  is  transferred  to  the  peritoneum,  and  causes 
paralysis  of  the  muscular  coat  above  the  stricture,  dilatation  of  the  in- 
testine and  ileus. 

It  follows  that,  to  appreciate  the  causes  of  ileus  arising  from  scirrhous 
strictures  of  the  intestine  correctly,  we  must  take  into  consideration : 

Firstly ;  the  absolute  degree  of  stricture. 

Secondly ;  the  degree  of  attachment  of  the  aifected  portion  of  intes- 
tine, with  or  without  dislocation  and  inflection. 

Thirdly  ;  the  degree  of  the  consecutive  affection  of  the  part  above  the 
stricture. 

Fourthly ;  the  degree  of  the  inflammation  present. 

Appendix. — Diseases  of  Separate  Sections  of  the  Intestinal  Canal. 

Separate  sections  of  the  intestine  demand  special  attention,  inasmuch 
as  not  only  many  diseases  occur  more  frequently  at  one  part  than  at 
another,  and  are  subject  to  numerous  modifications  in  reference  to  their 
issue  and  result,  but  as  many  diseases  exclusively  affect  one  portion  of 
the  intestine.  We  shall  consider  the  diseases  of  the  duodenum,  of  the 
caecum  and  vermicular  process,  and  of  the  rectum,  separately,  on  account 
of  their  peculiar  importance. 

a.  Diseases  of  the  duodenum. — We  frequently  meet  with  cellular  ad- 
hesions between  the  upper  transverse  portion  of  the  duodenum  and  the 
concave  surface  of  the  liver  and  the  gall-bladder. 

The  mucous  membrane  of  the  duodenum  not  unfrequently  bulges  out 
through  the  muscular  coat  in  the  shape  of  a  hernial  diverticulum,  an 
occurrence  which  is  undoubtedly  favored  by  the  absence  of  the  peritoneal 
investment. 

Catarrhal  irritation,  and  even  inflammation,  undoubtedly  often  affect 
the  duodenal  mucous  membrane,  and  are  frequently  induced  by  an 
anomalous  condition  of  the  bile.  It  appears  that  they  may  extend  to  the 
biliary  ducts,  and  induce  icteric  symptoms  by  a  retention  of  the  bile 
(Stokes).  We  often  find  evidence  of  chronic  catarrh  or  blennorrhcea  of 


ABNORMITIES    OF    THE 

the  mucous  membrane  in  the  dead  subject,  accompanied  by  brownish-red 
or  slate-gray  discoloration,  by  hypertrophy  of  the  mucous  membrane  and 
Brunner's  glands,  and  by  the  formation  of  polypi. 

As  regards  ulcerative  processes,  we  find,  besides  tubercular  ulcer,  which 
is  very  rare,  the  perforating  ulcer  occurring  at  the  upper  transverse  por- 
tion (vide  perforating  gastric  ulcer),  and  perforation  resulting  from  an 
extension  of  the  process  from  the  gall-bladder  to  the  duodenum. 

Carcinoma  very  seldom  occurs  in  any  shape  as  a  primary  affection  of 
the  duodenum ;  it  is  sometimes  secondarily  attacked  posteriorly  by  an 
extension  of  the  disease  from  the  cancerous  lymphatic  glands  surrounding 
the  head  of  the  pancreas  and  the  gall-ducts. 

b.  Diseases  of  the  caecum  and  the  vermicular  process. — The  caecum 
and  the  vermicular  process  are  occasionally  absent,,  or  are  only  imper- 
fectly developed;  in  some  cases  the  former  has  been  found  fissured 
(Fleischmann). 

Anomalies  in  the  position  of  the  caecum  are  confined  to  its  position  on 
the  left  side  in  lateral  dislocation  of  the  abdominal  viscera,  and  to  its 
position  in  large  inguinal  or  umbilical  hernia.  Its  attachments  are  some- 
times very  loose,  and  this  appears  to  result  from  repeated  dilatation. 

Catarrhal  inflammation  of  the  caecal  mucous  membrane  is  remarkable 
on  account  of  the  frequency  of  its  occurrence,  and  that  form  which  is  oc- 
casioned by  habitual  constipation,  so-called  typhlitis  stercoralis,  is  pecu- 
liarly characteristic.  It  chiefly  originates  in  sedentary  habits,  indiges- 
tible food,  and  rheumatism  of  the  muscular  coat.  The  symptoms  are 
those  of  catarrhal  inflammation  generally ;  it  runs  an  acute  course,  is 
subject  to  frequent  relapses  and  degenerates  into  the  chronic  form.  Re- 
moval of  the  accumulated  pus,  and  avoidance  of  fresh  accumulations, 
generally  suffice  to  establish  a  cure.  If  this  is  not  effected,  ulcerative 
destruction  of  the  mucous  membrane,  and  continued  sinuous  suppuration 
of  the  muscular  coat,  result.  In  this  manner  rapid  perforation  of  the  in- 
testinal parietes,  and  especially  of  the  posterior  side,  may  follow,  either 
inducing  extensive  inflammation,  ichorous  destruction  of  the  cellular 
tissue  in  the  iliac  and  lumbar  regions  and  death  ;  or  giving  rise  to  general 
peritonitis,  in  consequence  of  the  destructive  process  passing  from  the 
right  iliac  region  in  a  different  direction. 

In  the  chronic  form  the  cellular  tissue  at  the  posterior  surface  of  the 
intestine  condenses,  and  the  adjoining  muscular  coat  and  the  entire  caecum 
shrivel  up ;  on  cessation  of  the  ulcerative  process,  the  caecum  is  found 
converted  into  a  slate-colored  capsule,  with  dense  parietes,  of  the  size  of 
a  walnut  or  a  pigeon's  egg ;  in  the  place  of  the-mucous  membrane  there  is 
a  sero-nbrous,  retiform  and  trabecular  tissue. 

In  reference  to  the  caecum  we  observe,  that  the  inflammation  of  the 
loose,  stringy,  cellular  tissue  external  to  the  iliac  fascia  (perityphlitis), 
is  of  considerable  importance.  It  is  occasionally  idiopathic,  but  more 
frequently  metastatic ;  it  is  very  dangerous,  both  on  account  of  the  facility 
with  which  the  pus  spreads,  and  on  account  of  the  perforation  of  the 
caecal  parietes  which  may  ensue,  and  the  consequent  extravasation  of  in- 
testinal contents  into  the  seat  of  inflammation. 

The  vermicular  process  is  sometimes  reduced  to  a  mere  cellular  sinus' 


INTESTINAL    CANAL.  89 

of  the  crccum ;  it  varies  in  size  from  that  of  an  insignificant  nodule  to  five 
or  six  inches. 

There  are  considerable  variations  in  the  position  of  the  caecum. 

Adhesions  of  its  free  extremity  may  become  a  matter  of  importance 
forming  rings  or  fissures  in  which  the  intestine  is  strangulated. 

Catarrhal  inflammation  of  the  vermicular  process  is  a  disease  of  common 
occurrence,  and  very  dangerous  on  account  of  its  consequences.  It  much 
resembles  typhlitis  stercoralis,  and  is  invariably  the  result  of  faecal  mat- 
ters and  foreign  bodies,  especially  small  fruit-stones,  having  become 
lodged  and  hardened  in  it. 

The  affection  has  a  torpid  character,  may  exist  for  a  long  period  as 
blennorrhcea,  and  is  accompanied  by  thickening  of  the  coat  of  the  vermi- 
cular process.  After  frequent  exacerbations  it  passes  into  ulceration, 
which  may,  if  the  foreign  body  remains  loose,  attack  the  entire  process, 
or  if  the  former  becomes  fixed,  affect  only  the  point  of  attachment,  or  the 
vermicular  process.  In  the  second  case,  the  constant  irritation  at  one 
spot,  or  the  accumulation  of  ulcerative  secretion  and  the  consequent  dis- 
tension, induce  a  rapid  development  of  the  morbid  process. 

Under  favorable  circumstances,  especially  if  the  foreign  body  is  dis- 
charged, the  ulceration  terminates,  and  the  vermicular  process  partially 
or  entirely  shrivels  up  and  forms  a  lead-  or  slate- colored  ligamentous  ap- 
pendix. 

In  the  opposite  case  the  ulceration,  especially  when  gangrene  is  super- 
induced, more  or  less  speedily  brings  on  perforation  of  the  vermicular 
process  ;  this  may  occur  at  various  points,  sometimes  at  or  near  the  ter- 
mination, sometimes  at  the  circumference,  in  such  a  manner  as  to  cause 
a  division  into  two  parts.  This  perforation  and  the  consequent  discharge 
of  the  purulent  contents  into  the  peritoneal  cavity,  are  not  immediately 
followed  by  general  peritonitis,  inasmuch  as  the  previous  irritation  has 
induced  adhesions  with  the  neighboring  peritoneal  folds,  which  render 
the  ultimate  perforation  innocucous  for  a  time,  as  far  as  regards  the  re- 
mainder of  the  peritoneum.  In  the  interior  of  the  circumscribed  cavity 
the  ulcerative  process  in  the  mean  while  continues,  the  adhesions  gradu- 
ally give  way,  and  general  peritonitis  ensues. 

We  further  occasionally  observe  a  metamorphosis  of  the  vermicular 
process  produced  by  obturation,  which  is  analogous  to  dropsy  of  the  ef- 
ferent ducts  of  glands,  and  which  is  most  apparent  in  the  gall-bladder 
(hydrops  cystidis  fellese).  The  foreign  body  sometimes  attaches  itself  to 
a  certain  point  and  closes  the  canal  without  inducing  ulceration ;  in  con- 
sequence of  an  accumulation  of  the  mucous  secretion  the  vermicular  pro- 
cess dilates,  the  mucous  membrane  thins  and  is  gradually  converted  into 
a  serous  membrane  which  secretes  an  albuminous  fluid.  The  vermicular 
process  is  thus  metamorphosed  into  an  hydropic  capsule,  which  in  the 
course  of  time  certainly  may  become  the  seat  of  inflammation,  resulting 
in  ulceration  and  perforation. 

Typhous  and  tuberculosis  affections  frequently  extend  to  the  vermicular 
process,  and  both  may  be  followed  by  perforation. 

c.  Diseases  of  the  rectum. — The  main  defect  of  development  to  which 
the  rectum  is  liable,  is  that  represented  by  atresia  ani,  or  congenital  oc- 
clusion of  the  anus.  In  this  case  the  rectum  either  has  a  blind  termina- 


90  ABNORMITIES    OF    THE 

tion,  is  absent,  or  opens  into  the  urinary  and  genital  passages  (cloaca). 
In  the  first  case  the  rectum  may  reach  down  to  the  point  where  the  orifice 
should  be,  but  the  orifice  is  closed  by  an  expansion  of  the  common  integu- 
ments over  it ;  these  are  distended  by  an  effort  at  defecation,  and  the 
meconium  may  even  be  seen  through  them.  There  may  however  be  a 
greater  deficiency  of  the  rectum,  the  latter  terminating  at  a  higher  point, 
or  it  may  be  totally  absent,  and  its  place  be  occupied  by  dense  cellular 
tissue.  In  these  cases  the  pelvis  appears  in  an  undeveloped  state,  espe- 
cially in  its  antero-posterior  diameter ;  it  is  very  much  inclined,  and  the 
external  genital  organs  are  placed  very  far  back.  This  affords  a  valuable 
aid  in  the  diagnosis,  as  it  allows  us  to  infer  a  considerable  deficiency  in 
the  rectum. 

Anomalies  in  the  calibre  of  the  rectum  are  both  frequent  and  important, 
and  appear  in  the  form  of  dilatations  or  contractions.  The  former  attain 
a  very  considerable  extent,  presenting  sacculated  sinuses,  and  an  accumu- 
lation of  indurated  fteces ;  they  are  accompanied  by  considerable  thicken- 
ing of  the  coats  and  blennorrhcea.  The  latter  vary  much  in  form  and 
distribution,  but  more  still  in  respect  of  their  causation.  In  the  first 
place,  the  rectum  is  more  liable  than  any  other  portion  of  intestine  to  be 
compressed  by  neighboring  viscera,  by  the  pregnant  uterus,  by  tumors 
developed  in  the  uterine  or  vaginal  parietes,  by  diseased  ovaries,  the  re- 
troverted  uterus,  the  hypertrophied  prostate,  vesical  calculi,  pessaries,  &c. 
The  contractions  dependent  upon  disease  of  the  coats  of  the  rectum  are  of 
still  greater  importance.  To  these  belong  contractions  from  hypertrophy 
of  the  coats,  accompanied  by  an  accumulation  of  fat,  and  induration  of 
the  surrounding  cellular  tissue  ;  contraction  consequent  upon  catarrhal 
inflammation  and  suppuration,  or  gonorrhoeal  ulcer  ;  contraction  resulting 
from  a  dysenteric  cicatrix,  polypous  tumors,  and  various  forms  of  cancer. 
Of  these  the  strictures  consequent  upon  dysentery  and  cancer  are  the 
most  important. 

Hypertrophy  of  the  sphincter  is  a  remarkable  affection ;  it  may  in  rare 
cases,  especially  in  children,  give  rise  to  obstinate  constipation  and  even 
ileus,  but  it  frequently  induces  excoriation  of  the  mucous  membrane,  the 
so-called  fissure  of  the  rectum. 

We  have  already  (p.  56)  discussed  prolapsus  ani. 

Catarrh  and  blennorrhoea,  accompanied  by  hypertrophy  of  the  coats, 
which  frequently  gives  rise  to  plicated  and  polypous  excrescences  of  the 
mucous  membrane,  are  very  frequent  affections  of  the  rectum.  Gonor- 
rhoeal catarrh  of  the  rectum  represents  a  peculiar  variety :  it  affects  the 
same  uniformly,  or  in  a  circumscribed  spot :  in  the  former  case  it  is  fol- 
lowed by  a  shrivelling  of  the  rectum,  and  the  mucous  membrane  gra- 
dually disappears ;  in  the  latter  by  a  callous  induration  of  the  coats  of 
the  rectum,  and  not  unfrequently  by  the  formation  of  an  ulcer,  which 
as  well  as  the  stricture  is  placed  in  the  vicinity  of  the  sphincters,  and  is 
distinguished  by  its  zonular  form,  its  sinuous  circumference,  and  its  cal- 
lous puckered  base. 

The  hemorrhoidal  ulcer  is  peculiar  to  the  rectum.  It  results  from  the 
irritation  of  the  mucous  membrane,  produced  by  lasting  congestion  in 
inversion  and  prolapsus,  strangulation  by  the  sphincters,  compression  of 
the  hemorrhoidal  swellings,  and  undue  medicinal  interference.  It  is 


INTESTINAL    CANAL.  91 

distinguished  by  its  seat  in  the  vicinity  of  the  sphincters,  its  irregular 
shape,  its  indented  and  sinuous  flabby  margin  of  mucous  membrane,  and 
the  similar  ridges  of  mucous  membrane  that  surround  or  pass  over  it. 
On  account  of  the  absence  of  reaction  in  the  parts,  corrosion  of  the 
vessels  not  unfrequently  brings  on  violent  hemorrhage. 

An  inflammation  of  cellular  tissue  resembling  perityphlitis,  occurs  in 
the  rectum,  as  periproctitis.  The  remarks  made  in  reference  to  the 
former  apply  to  the  latter  also  (vide  p.  88).  It  occasionally  becomes 
chronic,  and  thus  induces  hypertrophy  and  callosity  of  the  cellular  and 
adipose  tissues  surrounding  the  rectum,  which  however  differ  from  the 
analogous  result  of  cancer.  Like  the  hemorrhoidal  ulcer,  it  may  cause 
fistula  recti. 

Of  intestinal  cancerous  affections,  those  occurring  in  the  rectum  are 
the  most  frequent,  especially  if  we  include  the  scirrhous  degenerations 
which  involve  it  by  extension  from  the  female  sexual  organs,  but  which 
we  do  not  allude  to  at  present. 

Cancerous  disease  attacks  the  rectum  in  the  various  forms  above  de- 
scribed as  affecting  the  intestine  at  large.  The  following  however  are 
particularly  remarkable : 

a.  Erectile  tumors  developed  in  the  tissue  of  the  mucous  membrane, 
and  infiltrated  with  medullary  carcinoma ;  they  assume  the  shape  of 
broad,  sessile,  or  pediculated  fungi.  They  are  commonly  placed  at  the 
commencement  and  posterior  surface  of  the  rectum,  at  about  three  or 
four  inches  from  the  orifice ;  we  find  these  excrescences  only  in  excep- 
tional cases,  at  or  close  to  the  sphincters. 

/5.  Annular  carcinoma  and  stricture  of  the  rectum.  It  occurs  almost 
exclusively  at  the  upper  portion  of  the  rectum,  and  especially  at  the 
point  at  which  the  sigmoid  flexure  terminates  in  the  rectum,  and  which, 
in  its  normal  condition,  presents  a  distinct  contraction.  The  strictured 
part  is  either  unattached,  or,  as  is  more  commonly  the  case,  firmly  agglu- 
tinated laterally  to  the  promontory;  notwithstanding  its  elevated  position, 
it  is,  as  Cruveilhier  correctly  remarks,  pushed  down  by  the  feculent  accu- 
mulations above,  which  generally  precede  the  occurrence  of  ileus,  it  is 
therefore  easily  reached  in  exploring  with  the  finger. 

Y*  Scirrhous  degeneration  of  the  rectum  over  a  large  surface,  or 
throughout  its  entire  extent. — This  primarily  affects  the  submucous  cel- 
lular tissue,  from  which  it  extends  through  the  entire  muscular  coat  to 
the  cellular  sheath  of  the  intestine,  the  cellular  and  adipose  tissue  of  the 
pelvic  cavity,  to  the  posterior  surface  of  the  vagina,  and  even  to  the 
uterus ;  or  it  originally  attacks  one  of  the  last-named  tissues,  and  involves 
the  rectum  secondarily.  The  rectum  is  firmly  attached,  from  being 
agglutinated  in  its  entire  extent  to  the  sacrum,  or  adherent  to  the  vagina, 
or  it  appears  wedged  into  the  pelvis  by  the  surrounding  morbid  growth ; 
its  calibre  may  be  variously  diminished,  though  it  sometimes  is  unal- 
tered ;  its  internal  surface  is  uneven,  nodulated,  and  hard,  or  it  is  filled 
with  soft,  fungous,  bleeding  growths ;  the  anus,  especially  if  the  morbid 
product  extends  to  the  sphincters,  is  patent,  everted,  and  varicose ;  even 
the  perineum  appears  more  or  less  swollen,  protruded,  and  hardened ; 
and  this  induration  extends  to  a  considerable  extent  over  the  nates  in 
consequence  of  the  condensation  of  the  subcutaneous  adipose  tissue. 


92  ABNORMITIES    OF    THE 

The  foreign  bodies  found  in  the  rectum  may  either  have  reached  it 
from  above,  but  not  proving  injurious  until  they  reach  this  point,  or 
they  may  have  been  introduced,  per  anum,  in  consequence  of  morbid 
sensations  or  perverted  sexual  desire.  In  the  latter  case  they  are  com- 
monly very  singular  objects  and  of  alarming  size. 

§  6.  Anomalies  of  the  Intestinal  Contents. — 1.  Excessive  accumula- 
tion of  gas  is  very  frequently  caused  by  an  increase  in  the  secretion  on 
the  internal  surface  of  the  intestine,  accompanied  by  an  impediment  to 
its  escape.  This  occurs  over  a  large  extent  of  intestine  in  morbid  affec- 
tions of  the  mucous  membrane,  and  especially  in  the  exudative  processes, 
such  as  typhus,  in  the  shape  of  tympanitis ;  the  escape  of  the  gas  is 
impeded  by  the  paralyzed  state  of  the  muscular  coat.  This  condition 
also  accompanies  anomalous  states  of  other  intestinal  secretions,  espe- 
cially of  the  intestinal  mucus,  or  morbid  affections  of  the  nervous,  espe- 
cially the  ganglionic,  system ;  in  the  latter  instance,  however,  there  is 
frequently  no  increase  in  the  amount  of  gas  secreted,  but  in  consequence 
of  the  atony  of  one  portion  of  intestine,  and  spasmodic  contraction  of 
the  remainder,  or  of  atony  of  the  entire  tube,  it  accumulates,  and  is 
retained  in  the  shape  of  tympanitis  throughout  the  canal. 

Occasionally,  an  excessive  accumulation  of  gas  is  brought  on  by  the 
consumption  of  certain  flatulent  articles  of  diet  in  a  debilitated  state  of 
digestion,  or  where  there  is  an  absence  of  the  due  amount  of  bile. 

2.  The  intestinal  mucus  is  very  often  found  in  excess,  and  occasionally 
the  amount  secreted  is  insufficient :  in  the  former  case,  it  also  undergoes 
considerable  modifications  as  to  quality.     The  increase  of  secretion  either 
exists  throughout  the  intestinal  canal,  or  affects  certain  sections  in  the 
shape  of  chronic  catarrh  or  blennorrhoea ;    the  mucus  is  either  milky, 
white,  yellowish  and  purulent,  or  glutinous,  transparent,  vitreous,  spawny. 
In  the  congestive  state  of  typhous  and  typhoid  diseases,  we  find  a  pecu- 
liar gelatinous  mucus  on  the  intestinal  mucous  membrane,  and  more 
especially  on  that  of  the  small  intestine  and  caecum. 

A  diminution  in  the  quantity  of  mucus  accompanies  excessive  forma- 
tion of  bile  and  of  feculent  matter  (copropoesis). 

3.  There  can  be  no  doif  )t  that  a  peculiar  gelatinous  constitution  of 
the  mucus  is  the  nidus  of  intestinal  entozoa,  and  the  cause  of  helmin- 
thiasis.     There  are  two  orders  of  worms,  the  nematoidea  and  the  ces- 
toidea :  to  the  former  belong  the  ascaris  lumbricoides,  the  trichocephalus 
dispar,  and  the  oxyuris  vermicularis ;  to  the  latter,  the  taenia  solium  and 
the  botryocephalus  dispar. 

The  lumbricus  occurs  in  the  small  intestine  of  children  and  young 
persons,  and  is  sometimes  found  in  large  numbers,  forming  knotted  accu- 
mulations. It  often  ascends  to  the  stomach,  into  the  oesophagus  and 
pharynx,  it  may  even  pass  from  here  into  the  larynx,  and  thus,  as  has 
been  distinctly  observed,  produce  suffocation.  Occasionally,  several  lum- 
brici  may  be  found  undertaking  such  and  similar  preposterous  peregri- 
nations at  the  same  time. 

The  trichocephalus  dispar  inhabits  the  caecum  and  the  adjoining  por- 
tion of  the  small  intestine.  Its  occurrence  in  the  gelatinous,  feculent 
contents  of  these  parts  in  typhus,  is  very  important. 


INTESTINAL    CANAL.  93 

The  ox  juris  (ascaris)  vermicularis  inhabits  the  rectum. 

The  taenia  is  found,  one  or  more  in  number,  in  the  small  intestine. 

We  may  still  be  permitted  to  doubt  the  fact  that  the  entozoa  ever  per- 
forate the  intestine,  at  all  events,  it  is  a  very  rare  occurrence.  It  is  well 
established,  however,  nor  is  it  of  very  unusual  occurrence,  and  this  applies 
especially  to  the  lumbricus,  that  they  pass  through  orifices  in  the  intes- 
tinal parietes  into  the  abdominal  cavity,  into  abscesses,  into  the  bladder 
or  the  vagina. 

4.  The  fecal  matters  offer  various  important  points  for  consideration. 
They   sometimes   accumulate   in   the   intestine  to  an  extraordinary 

degree,  in  consequence  of  repletion,  torpor  of  the  intestine,  diminution 
of  the  intestinal  secretion,  increase  of  the  absorbent  powers  of  the  intes- 
tine, and  induration  of  the  faeces.  These  accumulations  occasionally 
affect  single  portions  of  the  intestine,  and  may,  if  persistent,  induce 
disease  of  the  coats. 

The  occurrence  of  an  excessive  elimination  of  faces  (copropoesis  exce- 
dens)  from  the  intestinal  secretions,  is  an  established  fact.  It  takes  place 
as  a  critical  discharge  in  various  diseases,  and  especially  in  those  that 
are  accompanied  by  increased  secretion  in  the  intestinal  canal ;  but  recent 
observations  have  demonstrated  its  occurrence  as  an  idiopathic  disease, 
which  may,  by  the  excessive  drain  it  causes,  give  rise  to  atrophy  of  the 
intestinal  coats  and  to  general  emaciation.  The  color  of  the  faeces 
mainly  depends  upon  the  color  and  degree  of  saturation  of  the  bile. 
They  may  be  dark-brown,  dark-green,  black,  pitchy,  or,  in  the  absence 
of  bile,  grayish  or  clayey.  Occasionally  the  faecal  discharge  is  brown 
internally,  and  invested  by  a  white  clayey  covering,  of  varying  thickness. 

The  consistency  of  the  faeces  varies  considerably  :  they  are  liquid  when 
the  serous  exhalation  of  the  mucous  membrane  is  excessive ;  semifluid 
when  the  secretion  is  muco-gelatinous ;  or  they  are  mixed,  with  the  secre- 
tion in  the  shape  of  flocculent  grumous  particles.  The  feculent  matter 
found  above  the  various  intestinal  strictures  presents  a  peculiar  frothy 
appearance. 

The  faeces  may  have  hardened,  so  as  to  present  lumps  or  scybala  of 
various  sizes.  This  scybalous  induration  generally  takes  place  in  the 
sigmoid  flexure  and  the  rectum,  though  it  occasionally  reaches  up  to 
the  caecal  valve.  If  accompanied  by  flatulency,  small  portions  of  fecu- 
lent matter  are  found  to  adhere  to  the  intestine,  and  after  the  mucus  by 
which  they  were  made  to  adhere  has  dried  up,  they  appear  agglutinated 
to,  and  even  imbedded  in,  the  internal  surface  of  the  intestine. 

Figured  fasces  either  form  cylinders,  which  may  be  variously  affected 
by  pressure  of  the  intestine  or  by  stricture,  or  they  form  tubers  of  various 
size.  This  leads  us  to  a  consideration  of  faecal  concretions  and  intes- 
tinal calculus. 

5.  Intestinal  concretions  are  either  formed  in  the  intestine,  or  after 
being  formed  external  to  it,  reach  it  by  the  natural  or  by  abnormal 
passages. 

To  the  former  belong  indurated  scybala,  which  may  be  produced  under 
all  the  circumstances  that  give  rise  to  a  retention  of  faeces ;  and  espe- 
cially the  tuberculated  faecal  concretions  that  form  in  and  adhere  to  the 
cavity  of  colonic  diverticula.  They  may  be  various  foreign  bodies,  such 


94  ABNORMITIES    OF    THE 

as  fruit-stones,  indigestible  portions  of  vegetables  or  pieces  of  bone,  which 
have  been  introduced  into  the  intestine,  and  become  incrusted  with  faecal 
matter.  Or  such  bodies,  especially  when  occupying  a  blennorrhoic  por- 
tion of  intestine,  as  the  vermicular  process  or  caecum,  give  rise  to  deposits 
of  grayish  fatty  matters,  chalky  and  saline  substances. 

To  the  latter  belong  biliary  calculi,  which  have  reached  the  intestine 
by  the  natural  passages,  or  by  ulcerative  communication ;  and  the  fatty 
and  chalky  concretions  which  have  formed  in  abscesses  adjoining  the 
intestine  and  have  passed  into  the  latter. 

Intestinal  concretions  prove  injurious  to  the  intestine,  in  proportion  to 
their  size  and  form,  as  we  shall  have  occasion  to  explain  further  on. 

With  regard  to  serous,  muco-serous,  albuminous,  puriform,  and  puru- 
lent discharges,  to  fibrinous  coagula,  and  pseudo-membranous  formations 
in  the  intestine,  we  refer  to  the  remarks  given  under  these  heads. 

6.  Blood  is  found  in  large  or  small  quantities,  coagulated  and  fluid, 
red  or  variously  discolored,  in  the  vicinity  of  the  point  at  which  it  was 
discharged,  or  extended  over  a  large  surface.  Hemorrhage  occurs  in 
consequence — 

Firstly ;  Of  active,  passive,  and  especially  of  mechanical  hyperaemia  ; 
the  latter  being  a  frequent  result  of  obstacles  in  the  portal  system. 
The  mucous  membrane  presents  no  essential  textural  alterations,  but  is 
either  congested  and  suffused,  or  in  consequence  of  the  excessive  hemor- 
rhage, pale  and  anaemic.  The  source  of  hemorrhage  is  scarcely  disco- 
verable. We  have  lately  seen  two  remarkable  cases  of  this  description, 
in  which  exhausting  hemorrhage  resulted  from  intense  and  extensive 
burns  of  the  abdomen. 

Secondly ;  In  consequence  of  the  various  exudative  processes  accom- 
panied by  solution  of  the  mucous  tissue  and  its  vessels,  e.  g.  in  dysentery. 

Thirdly ;  The  hemorrhage  may  be  caused  by  other  morbid  degenera- 
tions of  the  mucous  tissue,  e.  g.  erectile  fungoid  excrescences,  the  typhous 
deposit  at  the  period  of  metamorphosis,  or  torpid  ulcers. 

Fourthly ;  In  rare  cases  the  hemorrhage  results  from  the  rupture  of  a 
varicose  vein  in  the  submucous  tissue  of  the  intestine,  the  investing  mu- 
cous membrane  giving  way  at  the  same  time.  It  is  more  frequently 
caused  by  corrosion  of  an  artery  or  vein  at  the  base  of  a  hemorrhoidal 
ulcer  of  the  rectum. 

Every  variety  of  hemorrhage,  but  especially  the  one  first  cited,  is 
favored  by  diminished  density  of  the  blood. 

When  the  blood  is  found  extravasated  over  a  large  surface,  it  may 
have  come  from  above,  but  it  frequently  happens  that  the  source  of  the 
hemorrhage  is  below  the  extravasation ;  this  is  particularly  the  case  in 
hemorrhage  of  the  rectum. 

Moreover,  the  blood  may  have  reached  the  intestine  from  the  stomach, 
the  oesophagus,  the  hepatic  viscera,  and  even  from  the  respiratory  organs. 

The  longer  the  blood  remains  in  the  intestine,  the  longer  it  has  been 
exposed  to  the  operation  of  the  intestinal  secretions,  the  more  it  becomes 
discolored,  assuming  a  chocolate  or  black  tinge ;  and  when  it  has  ex- 
perienced the  influence  of  the  gastric  juice,  it  is  frequently  converted 
into  a  pitchy  or  tarry  mass.  Bile  in  a  very  concentrated  form  often 
presents  a  similar  appearance. 


INTESTINAL    CANAL.  95 

The  intestine  sometimes  offers  a  passage  by  which  acephalo-cysts  of 
the  liver  (the  so-called  hydatids)  are  discharged. 

7.  We  must  lastly  investigate  the  foreign  bodies  found  in  the  intestine. 

To  this  class  belong  concretions  formed  within  the  body,  and  especi- 
ally in  the  biliary  ducts,  and  substances  that  have  been  introduced  by 
mouth  or  per  anum.  They  prove  injurious  by  producing  lesions  of  the 
intestinal  parietes,  as  in  the  case  of  rough  or  pointed  bodies,  bones  or 
fragments  of  bone,  portions  of  stone,  glass,  needles,  &c.  After  attach- 
ing themselves  to  the  mucous  membrane,  suppuration  is  established,  and 
they  may  thus  escape  through  the  intestinal  and  abdominal  parietes ;  or 
the  perforation  may  communicate  with  another  portion  of  intestine,  or 
with  a  neighboring  hollow  organ,  and  the  escape  be  effected  through  the 
urinary  and  genital  organs.  The  foreign  bodies  may  also  block  up  the 
intestine  and  induce  ileus ;  these  cases  are  of  extreme  importance,  and 
they  admit  of  the  following  subdivision  : 

Firstly,  The  foreign  body  is  arrested  at  a  certain  point  of  the  intes- 
tine, in  consequence  of  its  rough  and  angular  form. 

Secondly,  the  foreign  body  is  retained  simply  from  a  disproportion 
between  the  calibre  of  the  intestine  and  the  size  of  the  substance,  and 
occlusion  is  the  result. 

Thirdly,  The  foreign  bodies  accumulate  to  a  considerable  number  at 
one  point,  and  the  consequent  extreme  dilatation  and  paralysis  of  the  in- 
testine induce  obstruction. 

Rough,  angular  bodies,  if  not  very  large,  frequently  pass  through  the 
intestine  without  difficulty,  in  an  envelope  of  mucous  and  feculent  mat- 
ter ;  but  they  often  become  attached  to  the  intestine,  by  inserting  their 
edges  and  processes  into  it,  and  may,  by  the  consequent  inflammatory 
swelling,  give  rise  to  an  obliteration  of  the  passage. 

Large  round  or  oval  bodies,  with  a  smooth  surface,  may  be  retained  at 
various  points  of  the  small  intestine,  but  especially  at  the  terminal  por- 
tion of  the  ileum,  which  presents  a  distinct  diminution  in  calibre. 

We  class  among  these  foreign  bodies  large  biliary  calculi,  which  have 
escaped  from  the  bile-ducts  into  the  intestine. 

Indigestible  substances  that  have  been  taken  in  large  quantities,  espe- 
cially the  peel  of  fruit,  cherry,  and  plum  stones,  often  accumulate  at 
particular  points  of  the  colon,  as  the  caecum  or  the  sigmoid  flexure. 
They  give  rise  to  uniform  or  lateral  dilatation  of  the  intestine,  accom- 
panied by  atony  and  paralysis  of  the  latter.  This  condition  may,  sooner 
or  later,  in  a  ratio  with  the  size  of  the  accumulated  mass,  give  rise 
to  ileus  ;  or  if  the  accumulation  is  inconsiderable,  and  the  action  of  the 
superior  portion  of  the  intestine  capable  of  effecting  a  partial  discharge, 
it  may  last  a  considerable  time,  and  end  in  a  cure  ;  or  it  results  in  chronic 
inflammation,  the  formation  of  sinuses,  and  the  ultimate  contraction  of 
the  intestine,  which  again  may  give  rise  to  occlusion. 

Appendix. — On  spontaneous  Ileus. 

We  distinguish  between  the  so-called  organic  ileus,  into  the  nature  of 
which  we  have  inquired  in  preceding  paragraphs,  and  dynamic  or  spon- 
taneous ileus.  The  latter  deserves  a  careful  investigation  of  its  cada- 


96  ABNORMITIES    OF    THE    INTESTINAL    CANAL. 

veric  relations,  the  more  so  as  a  sound  theory  of  its  nature,  based  upon 
practical  experience,  is  very  much  wanted. 

Ileus  is  a  rare  occurrence,  and  undoubtedly  often  dependent  upon 
atony  of  an  intestinal  segment,  which  must  be  viewed  as  the  proximate 
cause,  in  contradistinction  to  the  case  just  examined,  in  which  the  accu- 
mulation of  foreign  matter  is  the  primary  affection.  It  takes  its  origin 
in  a  sedentary  mode  of  life,  in  depressing  physical  conditions,  repletion, 
superstimulation  by  purgatives  and  injections,  rheumatic  affection  of  the 
intestine,  diseases  of  the  spinal  cord,  and  even  of  the  brain.  The  colon 
is  the  part  almost  invariably  affected.  Stagnation  and  accumulation  of 
the  faeces  in  the  affected  portion  of  intestine  follow,  dilatation  is  induced, 
and  the  atony  ends  in  paralysis  ;  when  this  happens,  ileus  is  at  hand. 
Its  actual  occurrence,  however,  as  well  as  the  improvement  and  cure  of 
the  affection,  depend  upon  the  state  of  innervation  in  the  upper  healthy 
portions  of  intestine.  If  the  action  of  these  portions  suffices  to  propel 
the  fasces  through  the  dilated  segment,  and  thus  from  to  time  to  empty 
it,  the  latter  may  resume  its  functions,  and  thus  return  to  a  healthy  con- 
dition. If,  however,  the  upper  portion  of  the  intestine  does  not  possess 
sufficient  power,  which  will  be  the  case  if  the  accumulation  be  excessive, 
or  the  paralyzed  segment  has  sunk  to  a  lower  region  of  the  abdomen, 
the  accumulation  will  proceed,  and  at  last  reach  up  to  the  healthy  intes- 
tine. Here  the  peristaltic  action  is  reversed,  the  faeces  are  thrown  back 
into  the  stomach,  and  are  expelled  from  there  by  vomiting. 

When  the  paralysis  has  reached  a  ^certain  point,  inflammation  and 
sloughing  set  in,  and  enteritis  peritonealis  results.  As  this  induces 
paralysis  of  the  muscular  coat  and  passive  dilatation  in  the  upper  portion 
of  the  intestine,  a  change  occurs  in  the  ileus,  inasmuch  as  the  point  at 
which  it  commences  advances  with  the  advance  of  the  inflammation. 

All  pathologists  of  distinction  deny  the  possibility  of  spasmodic  con- 
traction or  spasmodic  stricture  in  a  portion  of  the  intestine,  being  the 
cause  of  obstinate  constipation  or  of  ileus.  The  modus  operandi  of  the 
various  remedial  agents  employed  fully  confirms  the  theory  given  with 
regard  to  this  simple  form  of  ileus.  The  benefit  derived  from  purgatives 
is  to  be  explained  by  the  force  with  which  the  healthy  intestine  propels 
the  faeces  downwards,  and  the  rapidity  with  which  they  pass  through 
the  distended  portion ;  the  advantage  of  opiates  consists  in  diminishing 
the  activity  of  the  healthy  portion,  and  the  consequent  accumulation  in 
the  dilated  part,  and  in  allowing  the  latter  time  to  recover  its  activity. 

It  is  highly  probable  that  the  use  of  narcotic  enemata  of  tobacco  or 
belladonna,  effects  an  evacuation  of  the  dilated  portion,  by  inducing  a 
complete  relaxation  in  the  inferior  portion  of  intestine,  which  is  thus 
enabled  to  admit  and  convey  onwards  the  accumulated  faeces.  If  the 
injected  fluid  can  be  propelled  as  far  as  the  diseased  part,  the  discharge 
of  the  faeces  is  aided  by  the  mechanical  distension  of  the  intestine,  and 
is  undoubtedly  further  promoted  by  the  change  of  position  which  the  in- 
jection effects  in  the  healthy  intestine.  It  follows  that  injections  of 
fluids  that  exert  no  remedial  influence,  such  as  air,  may  effect  an  evacua- 
tion, and  thus  establish  the  first  condition  of  a  cure. 


ABNORMITIES    OF    THE    LIVER.  97 


CHAPTER  II. 


ABNORMITIES  OF  THE  ACCESSORY  ORGANS   OF  THE  ALIMENTARY 

CANAL. 


SECT.    I. — ABNORMITIES    OP   THE    LIVER. 

THE  diseases  of  the  liver  have  continued  to  remain  to  the  present  day 
a  subject  of  extreme  difficulty,  in  spite  of  the  progress  made  in  the  ana- 
tomy of  this  viscus.  As  one  of  the  chief  organs  concerned  in  sanguifica- 
tion, it  affects,  as  might  indeed  have  been  inferred  a  priori,  the  somatic 
and  psychical  character  of  the  individual  in  the  most  varied  and  exten- 
sive manner  within  the  range  of  physiological  bounds  ;  and  on  the  other 
hand,  many  of  its  morbid  affections,  which  are  beyond  the  reach  of  the 
scalpel,  become  intelligible  only  by  attending  to  the  anomalies  presented 
in  other  organs.  It  is  to  be  hoped  that  future  inquiries  may  elucidate 
them  more  fully  by  showing  the  influence  these  anomalies  have  upon  the 
constitution  of  the  blood,  and  by  explaining  the  various  spontaneous  de- 
rangements of  the  vital  fluid. 

§  1.  Arrest  and  Excess  of  Development. — The  liver  is  absent  in  very 
imperfect  monstrosities,  especially  in  acephalous  monsters,  in  which  the 
heart,  the  lungs,  and  the  greater  part  of  -the  intestinal  canal  are  also  de- 
ficient; in  biventral  monsters  the  liver  presents  more  or  less  marked 
traces  of  duplication. 

§  2.  On  the  Irregularities  of  Volume  generally,  and  on  Hypertrophy 
and  Atrophy  in  particular. — We  find  the  liver  either  abnormally 
enlarged  or  abnormally  diminished  in  size.  The  former  defect,  in  which 
the  left  lobe  remains  permanently  enlarged,  so  as  to  extend  to  the  left 
hypochondrium  and  beyond  the  spleen,  is  occasionally  congenital.  Both 
conditions,  when  acquired,  become  extremely  interesting  in  a  diagnostic 
point  of  view. 

Increase  in  the  volume  and  weight  of  the  liver  depends  upon — 

Firstly,  Hypersemia,  congestive  turgor  ; 

Secondly.  Inflammation,  inflammatory  swelling ; 

Thirdly,  Congestion  and  stasis  in  the  capillary  gall-vessels ; 

Fourthly,  True  uniform  hypertrophy  ; 

Fifthly,  Excessive,  but  morbid,  nutrition,  i.  e.  the  deposition  or  in- 
filtration of  a  substance  foreign  to  the  hepatic  tissue  in  quantity  or 
quality — conditions  which  have  hitherto  been  considered  as  hypertrophy 
of  one  of  the  component  parts  of  the  organ  ; 

Sixthly,  Adventitious  products,  which  directly  increase  the  weight  and 
volume  of  the  liver  in  proportion  to  their  own  number  and  size,  and  in- 
directly contribute  to  that  effect  by  the  congestion  they  give  rise  to  in 
the  surrounding  tissue. 

VOL.  II.  7 


98  ABNORMITIES    OF 

Diminution  in  the  volume  of  the  liver  is  the  result  of  atrophy  and 
alteration  in  the  tissue. 

a.  Hypertrophy. — Under  this  head  we  consider  not  only  the  abnormal 
condition  dependent  upon  exalted  nutrition  and  increased  deposition  of 
the  peculiar  normal  constituents  of  the  organ,  but  those  anomalies  also 
in  which  the  increase  of  size  is  the  result  of  excessive  deposition  of 
separate  elements  of  those  constituents,  and  of  the  deposition  of  hetero- 
geneous matter.  The  former  is  genuine  hypertrophy ;  the  latter,  which 
are  often  mistermed  hypertrophy,  includes  the  nutmeg  liver,  the  fatty 
liver,  and  its  variety  the  waxy  liver ;  and  lastly,  the  infiltration  of  an 
albuminous,  lardaceous,  and  gelatinous  substance. 

Although  the  last-named  abnormal  conditions  are  closely  connected 
with  deep-seated  constitutional  and  acquired  derangement  in  the  vegeta- 
tive sphere,  it  is  of  practical  utility  to  consider  them  in  this  section  until 
we  shall  have  arrived  at  an  accurate  knowledge  of  the  infiltrated  abnor- 
mal matter,  and  of  the  corresponding  anomalies  in  the  vegetative  system 
at  large.  We  are  the  more  justified  in  adopting  this  course  as  the 
enlargement  of  the  viscus,  and  especially  the  peculiar  features  in  its 
growth  which  are  perceptible  to  external  examination,  afford  a  valuable 
aid  in  the  recognition  of  these  internal  conditions. 

a.  Pure  hypertrophy,  i.  e.  a  simple  increase  of  the  normal  specific 
tissue,  can  scarcely  occur  without  uniform  hypertrophy  of  all  the  con- 
stituents of  the  liver.  It  is  not  unfrequent ;  it  is  a  result  of  hypersemia, 
and  presents  the  following  anatomical  signs :  the  liver  is  increased  in 
volume,  but  retains  its  usual  shape ;  it  is  hard,  lacerable  and  full  of 
blood ;  the  acini  appear  enlarged,  and  of  the  normal  reddish-brown 
color.  This  coarse-grained  texture  must  be  carefully  distinguished  from 
so-called  granular  liver. 

/?.  The  nutmeg  liver. — That  condition  of  the  liver  in  which  a  separation 
of  the  yellow  and  reddish-brown  substances  takes  place,  especially  if  the 
former  predominates,  and  which  presents  a  close  resemblance  to  the  sec- 
tion of  a  nutmeg,  has  been  termed  the  nutmeg-liver ;  it  is  commonly  con- 
sidered as  a  hypertrophy  of  the  so-called  white  or  secreting  portion, 
the  red  portion  either  remaining  unaltered  or  being  more  or  less  condensed 
by  the  former. 

According  to  our  own  researches  the  nutmeg  liver  occurs  under  two 
different  conditions,  and  there  are  consequently  two  varieties. 

aa.  In  one  case  it  appears  as  an  enlargement  of  the  capillaries  of  the 
biliary  canaliculi,  accompanied  probably  by  hypertrophy  of  the  latter 
(the  secreting  substance),  and  resulting  from  excessive  secretion  of  bile 
and  stasis  of  the  secretion.  The  two  substances  are  the  more  defined, 
the  darker  the  color  of  the  bile  and  of  the  red  substance. 

$3.  In  the  other  case  it  is  due  to  an  increased  deposit  of  the  fat  nor- 
mally due  to  the  liver. 

In  either  case  we  trace  several  degrees : 

Firstly,  In  the  lowest  degree  the  normal  distinction  between  the  two 
substances  is  simply  more  marked,  the  white  substance  appearing  more 
developed ; 

Secondly,  In  the  second  degree  the  predominance  of  the  white  sub- 


THE    LIVER.  99 

stance  becomes  more  apparent,  and  forms  circumvolutions  that  envelope 
the  red  substance ; 

Thirdly,  In  the  highest  degree  the  organ  approaches,  in  the  first 
variety,  to  the  granular ;  in  the  second,  to  the  fatty  liver. 

The  liver  appears,  in  the  second  variety,  to  be  slightly  enlarged,  at 
least  it  is  never  diminished  in  size ;  in  the  advanced  stages  it  has  a  ten- 
dency to  become  flattened,  and  to  expand  whilst  its  edges  are  thickened. 

Mechanical  hypersemia  of  the  portal  system  from  disease  of  the  heart 
is  peculiarly  liable  to  encourage  the  development  of  the  nutmeg  liver. 
The  affection  occurs  very  frequently ;  it  may  present  no  symptoms  what- 
ever, or  be  accompanied  by  distinct  signs  of  hepatic  disease,  though  not 
such  as  to  indicate  the  specific  derangement.  In  the  form  in  which  it 
presents  the  early  stage  of  the  fatty  liver,  it  most  probably  gives  rise  to 
the  numerous  complaints  which  are  relieved  by  neutral  salts,  alkalies, 
mineral  waters  containing  these  substances,  saponaceous  compounds,  and 
the  so-called  resolvent  vegetable  extracts. 

Y>  Fatty  liver,  the  adipose  metamorphosis,  morbid  accumulation  of  fat 
in  the  liver. — A  well-marked  case  is  distinguished  by  the  following  ana- 
tomical characters  :  the  liver  is  enlarged,  the  increase  of  size  taking  place 
chiefly  in  a  lateral  direction ;  its  edges  are  flattened  and  swollen,  the 
peritoneal  covering  is  smooth,  shining,  transparent  and  tense ;  the  organ 
is  soft  and  pits  on  pressure  ;  its  color,  internally  and  externally,  is  uni- 
formly yellowish-red  or  light  yellow,  resembling  that  of  autumnal  foliage  ; 
it  is  pale  and  exsanguine,  and  contains  a  large  amount  of  fat,  as  evidenced 
by  the  greasy  deposit  when  cut  with  a  dry  warm  blade,  or  as  proved  by 
submitting  the  liver  to  high  temperatures. 

The  disease  consists  in  a  deposition  of  free  adipose  tissue  to  such  an 
extent  as  not  only  to  replace  the  true  glandular  structure,  but  to  penetrate 
the  entire  parenchyma  to  the  exclusion  of  the  vascular  tissue. 

In  the  earlier  stages  of  the  affection  the  various  signs  alluded  to  are 
less  marked. 

Two  conditions  chiefly  favor  its  production : 

In  the  first  instance  it  very  commonly  accompanies  tubercular  phthisis  ; 
and,  according  to  the  researches  of  Louis,  is  found  in  two-thirds  of  all 
cases  of  phthisis.  Andral  has  explained  this  occurrence  on  the  ground 
of  impeded  secretion  of  hydrogen  by  the  lungs ;  but  extended  investigation 
allows  us  to  conclude  that  this  impediment,  which  is  not  even  demon- 
strable, is  not  the  cause  of  the  deposit ;  but  that  it  is  an  essential  consti- 
tuent or  pathognomonic  combination  of  the  tubercular  dyscrasia,  inasmuch 
as  it  allies  itself  with  tubercular  affections  of  every  kind,  with  tubercle 
of  the  intestinal  mucous  membrane,  of  the  bronchial  glands,  the  serous 
membrane,  the  bones,  &c. 

Secondly;  The  fatty  liver  is  also  developed — independently  of 
tubercle — in  consequence  of  a  luxurious  and  indolent  regimen,  in  children 
that  have  been  gorged  with  food,  and  especially  as  a  result  of  dram- 
drinking.  In  this  case  it  is  accompanied  by  accumulations  of  fat  in  the 
omentum,  the  mesenteries,  the  pericardium,  the  heart,  and  the  subcuta- 
neous cellular  tissue,  by  fatty  degeneration  of  the  muscular  fibres  of  the 
gall-bladder,  and  even  of  the  muscular  tissue  of  the  heart ;  the  common 
integument  has  a  leaden  hue,  and  the  perspiration  has  a  greasy  appear- 


100  ABNORMITIES    OF 

ance  and  a  peculiar  odor.  The  fat  bears  throughout  a  resemblance  to 
tallow. 

The  waxy  liver  is  a  variety  of  the  fatty  liver ;  it  is  distinguished  from 
the  latter  by  a  color  resembling  that  of  beeswax,  by  its  greater  consist- 
ence, dryness,  and  brittleness ;  and  these  qualities  depend  upon  a  peculiar 
modification  of  the  infiltrated  fat,  which,  although  accumulated  to  a  con- 
siderable amount,  leaves  but  few  traces  on  the  scalpel. 

Occasionally  the  tallow  is  seen  deposited  at  a  few  points  only,  or  it 
accumulates  at  particular  spots.  They  are  commonly  superficial,  though 
they  are  also  seen  in  the  deeper  parts  in  the  shape  of  irregularly-circum- 
scribed maculae,  which  are  the  more  conspicuous  by  their  change  of  color 
the  less  the  other  portions  of  the  liver  are  involved  in  the  disease,  and 
the  darker  they  are. 

o.  Lardaceous  (speckig,  baconny)  liver. — Next  in  order  to  the  fatty 
liver  are  the  infiltrations  of  the  hepatic  parenchyma  by  a  coarser,  gray, 
sometimes  transparent,  albuminous,  lardaceous,  or  lardaceo-gelatinous, 
substance.  This  affection  is  found  concurrent  with  constitutional  disease 
of  the  vegetative  system,  especially  with  scrofulous  and  rickety  disease, 
with  syphilitic  and  mercurial  cachexia,  and  it  may  consequently  be  con- 
genital. It  appears  that  it  is  occasionally  developed  as  a  sequela  of  in- 
termittent fever  in  cachectic  subjects. 

The  following  are  its  anatomical  characters :  considerable  increase  of 
size  and  weight,  with  remarkable  lateral  development  and  flattening  of 
the  organ  ;  smoothness  and  tenseness  of*the  peritoneal  investment,  a  cer- 
tain degree  of  doughy  consistency  combined  with  hardness  and  elasticity, 
anaemia,  pale,  watery,  portal  blood ;  gray,  grayish-white,  or  grayish-red 
color,  tinged  with  yellow  or  brown ;  the  surface  of  a  section  being  smooth, 
and  homogeneous,  resembling  bacon,  and  leaving  but  a  slight  fatty  stain 
on  the  scalpel.  Sometimes,  however,  there  is  an  adipose  deposit  in  the 
entire  liver,  or  in  certain  parts  of  the  organ,  and  the  blade  of  the  scalpel 
then  shows  the  fatty  appearance  when  a  section  is  made. 

In  many  cases  the  foreign  substance  is  also  deposited  in  the  shape  of 
white  lardaceous  spots,  the  edges  of  which  are  not  distinctly  circum- 
scribed. 

The  spleen  is  very  commonly  affected  in  a  corresponding  manner ;  it 
is  found  much  enlarged,  and  infiltrated  by  a  similar  substance  (vide  Spleen). 
Bright's  disease  of  the  kidneys  and  analogous  renal  affections  are  also 
very  often  complicated  with  the  lardaceous  and  fatty  liver. 

b.  Atrophy. — Atrophy  of  the  liver,  independent  of  the  marasmus 
senilis  of  the  organ,  appears  in  various  forms.  We  first  draw  attention 
to  two  distinct  forms  which  have  not  been  remarked  hitherto,  and  which, 
similarly  to  the  hypertrophic  affections,  are  the  expressions  of  a  consti- 
tutional malady,  and  have  their  immediate  origin  in  anomalies  of  the 
blood.  Owing  to  their  distinctive  coloring,  they  may  be  appropriately 
termed  yellow  and  red  atrophy. 

a.  Yellow  atrophy. — This  affection  is  characterized  by  the  saturated 
yellow  color,  owing  to  a  diffusion  of  bile  throughout  the  tissue,  by  extreme 
flabbiness  and  pulpiness,  loss  of  the  granular  texture,  extreme  rapidity 
in  the  reduction  of  size,  which  chiefly  affects  the  vertical  diameter,  and 
consequently  induces  a  flattening  of  the  liver.  It  occurs  chiefly  in  the 


:  ;  i  -^  '. 
THE  LIVER.  '''-' 


early  years  of  life,  during  puberty,  and  in  the  prime  ;  it  is  remarkable 
for  the  rapid  course  it  runs,  for  extreme  tenderness  of  the  liver,  nervous 
attacks,  and  jaundice  ;  it  terminates  fatally  with  febrile  symptoms  of  a 
disorganized  state  of  the  blood,  irritation  of  the  brain  and  its  membranes, 
and  hydrocephalic  softening  of  the  former,  and  with  symptoms  of  exuda- 
tion and  suppuration  generally,  and  especially  of  the  mucous  membrane, 
pneumonia,  &c. 

The  blood  contained  in  the  large  vessels  of  the  liver,  and  even  that 
contained  in  the  trunk  of  the  vena  portae,  is  reduced  in  consistence,  and 
of  a  dirty  reddish-brown  color  ;  and  the  coats  of  the  latter  vessel  are 
tinged  with  bile.  This  points  to  the  fact  that  the  portal  blood  itself  con- 
tains such  an  excess  of  biliary  constituents,  that  they  are  separated  here, 
and  still  more  in  the  capillaries,  and  thus  fill  the  entire  vascular  and 
biliary  system  ;  the  coats  of  the  vessels  and  their  cellular  strata  thus 
absorb  bile  by  exosmosis,  the  true  glandular  tissue  fuses,  is  lost  in  the 
biliary  colliquation,  and  disappears.  The  immediate  consequences  of  this 
condition  are  that  the  blood  in  the  vena  cava  is  infected  and  overcharged 
with  bile,  causing  intense  jaundice  ;  when  this  has  reached  a  certain 
point,  the  above  symptoms  terminate  in  a  rapid  consumption  of  the  blood 
and  in  exhaustion.  We  commonly  find  biliary  matter  of  a  deep  yellow 
color,  or  if  the  disorganized  blood  has  exuded  through  the  mucous  mem- 
brane, a  black  tarry  substance  in  the  intestine. 

,?.  Red  atrophy.  —  This  is  distinguished  from  the  former  by  its  dark- 
brown  or  bluish-red  color  ;  the  liver  is  gorged  with  blood,  and  presents  a 
spongy  elastic  consistency  ;  there  is  an  absence  of  granulation,  and  a 
section  offers  an  appearance  of  perfectly  homogeneous  texture  ;  the  organ 
is  reduced  in  size,  though  its  thickness  preponderates  over  the  other 
dimensions. 

The  disease  is  chronic,  and  is  always  accompanied  by  torpor  of  the 
abdominal  ganglia,  venous  plethora  of  the  abdominal  viscera,  and  by  the 
formation  of  brownish-black,  or  greenish-black,  tarry  bile,  and  faeces  of 
a  similar  constitution.  By  itself  it  rarely  proves  fatal,  though  death 
may  ensue  from  the  marasmus  brought  on  by  the  enduring  congestion  of 
the  portal  system.  In  addition  to  these  two  forms,  we  consider  — 

Y.  Laennec's  cirrhosis  in  its  advanced  stage,  a  chronic  affection  which 
resembles  acute  yellow  atrophy,  but  besides  being  chronic,  is  distinguished 
from  the  latter  by  the  liver  being  firm,  or,  if  flabby,  very  tough. 

Granular  liver  is  a  variety  of  this  species  ;  it  appears  essentially  as 
secondary  textural  degeneration,  and  although  commonly  treated  of  as 
atrophy,  and  from  ignorance  of  the  above  described  forms  as  the  only 
variety  of  atrophy,  we  refer  for  a  minute  examination  to  a  subsequent 
portion  of  this  work.  Finally,  we  have  — 

o.  Atrophy  of  the  liver  from  obliteration  of  the  ramifications  of  the 
vena,  porta  (vide,  the  acquired  Lobular  Form  of  the  Liver,  p.  103). 

§  3.  Abnormities  of  Form.1  —  These  abnormities  are  either  congenital, 
and  are  then  in  part  foetal  conditions  of  the  liver,  in  part  acquired.  To 
the  former  belong  the  round,  the  unlobulated,  or  but  slightly  lobulated 
(embryonic)  liver,  the  semiglobular,  the  broad,  the  flattened,  the  trian- 
gular and  quadrangular,  and  multilobular  liver. 

1  Oestr.  Jahrb.  xx.  4. 


102  ABNORMITIES    OF 

The  acquired  irregularity  of  form  is  either  the  result  of  external  influ- 
ences, or  it  depends  upon  an  affection  of  the  tissue  of  the  liver.  The 
former  consists  in  a  flattening  of  the  liver  anteriorly,  in  indentations  or 
furrows,  produced  by  contractions  or  deformities  of  the  thorax,  by  stays, 
exudations,  enlarged  viscera,  or  morbid  growths.  The  latter  are  of  pecu- 
liar interest,  as  the  nature  of  the  hepatic  malformation,  taken  in  connec- 
tion with  the  increase  or  diminution  of  size,  is  characteristic  of  the  inter- 
nal affection  of  the  viscus.  We  shall  devote  some  further  consideration 
to  this  class. 

Malformations  of  the  liver  must  be  considered  in  reference  : 

Firstly,  To  the  relation  of  the  vertical  to  the  longitudinal  and  trans- 
verse diameters,  or  the  circumference  of  the  edges  ; 

Secondly,  To  the  condition  of  the  edges,  which  may  be  bevelled  off, 
thinned,  acuminated,  or  thickened,  enlarged,  and  rounded ; 

Thirdly,  To  the  state  of  the  surface,  which  may  be  variously  smooth 
and  level,  or  as  variously  uneven. 

With  reference  to  the  first  variety,  we  are  able  to  affirm  that  the  de- 
velopment of  the  vascular  tissue  generally,  is  connected  with  swelling  and 
enlargement  of  the  liver  and  with  a  preponderance  of  the  vertical  diameter 
(thickness) ;  that  the  so-called  development  of  the  yellow  tissue  (infiltra- 
tion) is  complicated  with  lateral  enlargement,  or  increase  of  size  with 
flattening,  and  corresponding  diminution  of  the  vertical  diameter. 

In  reference  to  the  edges,  we  have  to  remark  that  in  the  last-named 
states,  at  least  in  their  advanced  degrees,  they  are  absolutely  thickened 
and  rounded. 

We  find  the  following  irregularities  of  form  to  occur  more  particularly 
in  connection  with  the  above-mentioned  varieties  of  enlargement. 

1st.  When  the  increase  of  size  is  the  result  of  congestion,  or  of  tempo- 
rary hypersemic  turgor,  the  liver  retains  the  general  outline  of  its  normal 
condition :  but  if  this  affection  becomes  permanent,  the  vertical  diameter 
soon  predominates  considerably.  This  is  still  more  the  case  in  genuine 
hypertrophy. 

2d.  The  nutmeg  liver,  the  fatty  and  waxy  and  lardaceous  liver,  induce 
a  lateral  enlargement  of  the  organ  :  the  vertical  diameter  diminishes,  and 
the  liver  is  flattened  :  this  becomes  more  apparent  when,  as  in  the  higher 
degrees,  there  is  at  the  same  time,  an  increase  in  the  substance  of  the 
edges,  i.  e.  when  the  latter  become  thicker  and  globose. 

An  evident  exception  occurs  when  this  condition  takes  place  in  early 
life,  or  when  it  is  congenital.  The  above-mentioned  irregularity  of  form 
is  in  that  case  less  marked,  as  the  preponderance  of  the  vertical  diameter 
of  the  liver  is  normal  in  the  foetal  state  and  during  the  first  years  of 
life. 

Even  in  the  varieties  of  atrophy  of  the  liver,  the  remarks  made  as  to 
the  alterations  of  form,  are  confirmed  in  the  main  ;  in  the  yellow  variety 
the  liver  is  generally  reduced  in  its  vertical  diameter,  whereas  in  the  red 
variety,  the  decrease  is  chiefly  perceptible  at  the  edges,  and  the  vertical 
diameter  consequently  predominates ;  in  the  former  case  the  organ  pre- 
sents a  disk-like  shape,  in  the  latter  that  of  a  hemisphere  or  ball. 

The  irregularity  of  form  consequent  upon  that  textural  disease  which 
is  called  the  granular  liver,  is  very  remarkable.  It  is  almost  always 


THE    LIVER.  103 

accompanied  by  a  considerable  diminution  of  size ;  the  granulations  and 
the  atrophy  generally  commence  at  the  edges,  and  the  latter  attains  its 
extreme  development  at  this  point ;  the  edges  consequently  appear  very 
much  thinned,  and  at  last  form  a  mere  seam,  consisting  of  cellule-fibrous 
tissue,  which  is  contained  between  two  condensed  laminse  of  peritoneum, 
and  reflected  over  the  convexity,  or  inverted  into  the  concavity  of  the 
liver.  The  left  lobe  of  the  liver  is  frequently  shrunk  into  a  very  small, 
flattened,  cellulo-fibrous  appendix,  and  the  thick  hemispherical  or  globu- 
lar mass  of  the  right  lobe  represents  the  entire  organ. 

Occasional  exceptions  arise  from  the  granular  disease  being  developed 
in  a  liver  that  was  previously  affected  by  some  other  disease,  as  by  the 
fatty  degeneration ;  in  this  case  the  reduction  in  size  only  takes  place 
very  slowly,  and  the  edges  instead  of  being  thinned  down,  are  often 
thickened  and  rounded. 

The  more  violent  inflammations  of  the  hepatic  peritoneal  lamina,  affect 
the  surface-layer  of  the  liver,  and  thus  induce  changes  in  form,  that  vary 
in  proportion  to  the  intensity  of  the  inflammation.  Thus  the  liver  is  not 
unfrequently  converted  into  a  thick  cake  with  rounded  edges,  if  the  in- 
flammation has  been  uniform,  or  it  may  be  converted  into  a  globular  mass, 
compressed  into  a  small  space  by  peritoneal  investment,  which,  in  conse- 
quence of  repeated  attacks  of  inflammation,  is  transformed  into  a  fibro- 
cartilaginous  tissue.  A  malformation  which  we  shall  have  occasion  to 
revert  to  subsequently  (superficial  lobulation)  results  from  an  intense 
development  of  this  process  in  detached  spots. 

The  surface  of  the  liver  offers  several  points  for  consideration. 

Hypersemic  turgor,  and  still  more  all  the  varieties  of  hepatic  infiltra- 
tion, are  distinguished  by  their  producing  a  smooth  surface. 

Unevenness  of  the  surface  is  produced  in  various  forms  and  degrees  ; 
the  chief  forms  are  the  racemose  and  the  lobulated. 

The  racemose  form  appertains  to  the  granular  liver ;  it  depends  upon 
the  granulation  of  the  peripheral  layer,  and  appears  delicately  or  coarsely 
moulded,  of  partial  or  uniform  occurrence,  in  proportion  to  the  develop- 
ment of  the  acini. 

The  lobulated  liver  is  either  a  congenital  abnormity  or  an  acquired 
malformation. 

The  congenital  form  of  this  affection  is  owing  to  an  arrest  of  develop- 
ment ;  the  liver  is  divided  into  several  lobes,  and  this  division  may  pro- 
ceed so  far  as  to  present  several  small  livers  which  are  only  connected 
with  the  main  organ  by  peritoneal  folds  and  the  vessels  enclosed  in  them. 
This  condition  is  not  accompanied  by  any  perceptible  shrivelling  or  con- 
densation of  the  peritoneum  in  the  fissures  or  sulci,  and  still  less  by  a 
condensation  of  the  parenchymatous  cellular  tissue,  or  an  obliterated 
state  of  the  vessels.  We  may  assume  d  priori,  and  experience  confirms 
the  view,  that  the  lobulation  commences  and  is  chiefly,  if  not  exclusively, 
developed  on  the  concave  surface  of  the  liver,  as  the  natural  point  of 
departure  for  the  fissures. 

Acquired  lobulation  of  the  liver  presents  itself  in  various  degrees,  and 
depends  upon  various  causes.  We  base  our  division  upon  the  latter,  and 
thus  arrive  at  their  chief  varieties,  which  at  the  same  time,  represent  as 
many  degrees. 


104  ABNORMITIES    OF 

Very  superficial  tabulation,  one  of  which  there  is  a  mere  indication,  is 
occasionally  the  result  of  superficial  inflammations  affecting  the  hepatic 
sheath.  These  induce  fibrous  condensation  of  the  parenchymatous  cellu- 
lar tissue,  and  cicatriform  contraction  of  the  investing  peritoneum,  be- 
yond which  the  neighboring  parenchyma  projects  in  the  shape  of  shallow, 
convex,  and  smooth  protuberances,  circumscribed  by  slight  furrows. 

A  second  form,  in  which  the  tabulation  is  more  marked,  is  developed 
in  the  granular  liver.  In  the  same  manner  as  the  granulations  may 
produce  a  racemose  appearance  of  the  hepatic  surface,  they  may,  when 
several  of  them  are  grouped  together,  produce  larger  protuberances, 
or  lobes ;  if  the  interstitial  cellular  tissue  is  much  condensed,  the  peri- 
pheral groups  may  become  pediculated,  so  as  to  resemble  mere  appen- 
dices. 

The  third  form  and  highest  degree,  which  bears  most  resemblance 
to  congenital  tabulation,  results  from  the  obliteration  of  one  or  more 
branches  of  the  vena  port93,  from  inflammation  and  the  consequent  shri- 
velling and  atrophy  of  the  hepatic  sections  supplied  by  their  ramifica- 
tions. These  sections  shrink  in  the  direction  of  the  obliterated  trunk, 
the  peritoneum  generally  follows,  the  surface  is  affected,  and  fissures  re- 
sult, which  run  in  various  directions,  and  above  which  the  healthy  tissue 
projects  in  the  shape  of  large  rounded  protuberances.  The  enlarge- 
ment of  these  protuberances  appears  to  be  encouraged  by  the  additional 
labor  thrown  upon  them,  and  still  more  so  if  these  portions  have  become 
the  seat  of  fatty  and  other  infiltrations.* 

Irregularities  of  the  hepatic  surface  of  a  different  kind  are  induced  by 
the  development  of  adventitious  products,  such  as  cancer  in  the  liver ; 
but  these  will  be  discussed  hereafter. 

§  4.  Abnormities  of  Position.  —  Abnormities  of  position  are  either 
congenital  or  acquired.  To  the  former  belong  the  abnormal  position  of 
the  liver,  external  and  internal  to  the  abdominal  cavity ;  as  in  cases  of 
fissure  of  the  abdominal  parietes  and  eventration,  of  deficient  diaphragm, 
of  congenital  umbilical  hernia,  of  lateral  transposition  of  the  viscera. 
In  the  latter  case,  the  entire  relations  of  the  organs  have  undergone  a 
corresponding  change,  the  large  right  lobe  now  being  on  the  left  side, 
and  vice  versa,  and  the  vesical  fossa  to  the  left  of  the  umbilical  fissure. 

Some  of  the  acquired  malpositions  of  the  liver  resemble  the  former, 
as  in  the  case  of  extensive  wounds  of  the  abdominal  parietes,  and  of  the 
diaphragm,  and  of  certain  rare  anomalies,  resulting  from  acquired  um- 
bilical hernia.  A  more  common  occurrence  is  the  abnormal  position  of 
the  liver  within  the  abdominal  cavity,  in  consequence  either  of  pressure 
exerted  by  other  viscera,  or  of  a  change  in  the  size  and  weight  of  the 
organ.  We  find  the  liver  and  the  neighboring  organs  pushed  out  of 
their  proper  place  by  distortions  of  the  spine  ;  by  hypertrophied  neigh- 
boring viscera,  e.  g.,  the  right  kidney,  by  expansions  of  adjoining  cavities, 
as  of  the  pericardium,  but  more  especially  of  the  right  pleura.  In  the 
latter  case  it  is  forced  down  into  the  mesogastric  region  by  the  dia- 
phragm which  is  depressed  by  the  accumulation  of  gases  or  fluids  in  the 
pleura  ;  and  as  the  pressure  especially  affects  the  right  lobe,  this  portion 
occupies  the  lowest  position,  and  comes  to  be  placed  under  the  left  lobe. 


THE    LIVER.  105 

The  liver  may  be  pushed  upwards  into  the  concavity  of  the  diaphragm 
and  into  the  thorax,  by  gaseous  accumulations  in  the  abdominal  cavity, 
by  ascites,  by  peritoneal  effusion,  and  by  tympanitic  distension  of  the 
intestines.  It  is  as  variously  affected  by  partial  exudations  and  by 
morbid  growths,  and  the  change  of  position  corresponds  to  their  seat 
and  magnitude. 

The  spontaneous  change  of  position  which  the  liver  undergoes  in  con- 
sequence of  increase  in  size  and  weight,  is  invariably  a  descent  to  a 
lower  region  of  the  abdomen,  and  it  follows  from  the  anatomical  rela- 
tions of  the  parts  that  it  must  be  the  right  lobe  which  is  peculiarly 
involved. 

§  5.  Changes  of  Consistency. — As  these  changes  are  always  allied  to 
other  anomalies  of  more  importance,  and  have  therefore  been  already 
alluded  to,  or  will  be  subsequently  considered,  we  here  only  advert  to 
the  diminution  in  the  consistency  of  the  organ  which  takes  place  without 
any  change  in  the  hepatic  tissue,  in  all  dyscrasic  processes  accompanied 
by  decomposition  or  subsequent  to  excessive  elimination  of  the  fibrine 
of  the  blood,  as  occurring  in  typhus  and  typhoid  states,  in  purulent  in- 
fection of  the  blood,  and  acute  tuberculoses,  or  subsequent  to  extensive 
exudation  on  serous  membranes,  and  especially  in  puerperal  fever.  The 
liver  appears  flabby,  collapsed,  and  pultaceous ;  its  parenchyma  is  soft- 
ened and  infiltrated  with  serum,  generally  very  pale  and  exsanguine,  or 
containing  only  pale,  thin,  and  watery  blood. 

§  6.  Diseases  of  the  Tissues,  a.  Hypercemia,  apoplexy,  anaemia  of 
the  liver. — Hypergemia  of  the  liver  appears  in  three  forms  :  as  active 
hypersemia,  resulting  from  idiopathic  or  consensual  irritation ;  as  passive 
hyperaemia,  dependent  upon  torpor  in  the  portal  vascular  system  ;  and 
lastly,  as  mechanical  hypersemia,  chiefly  induced  by  obstacles  in  the 
circulation  through  the  heart  and  lungs ;  the  last  form  is  one  of  very 
frequent  occurrence,  and  is  marked  by  the  intensity  and  extent  to 
which  it  affects  the  entire  viscera.  In  rare  cases  an  anomalous  anasto- 
mosis of  the  epigastric  cutaneous  veins  with  the  umbilical  veins  which 
have  remained  permanently  open,  gives  rise  to  persistent  hyperaemia  of 
the  liver.  (Vide  Veins.) 

The  anatomical  signs  are  congestive  turgor  of  the  viscus,  increase  of 
size,  especially  in  the  vertical  diameter,  but  without  any  further  change 
of  form,  dark-red  color,  and  obliteration  of  the  yellow  substance,  soften- 
ing of  the  parenchyma,  and  a  large  supply  of  blood.  In  habitual,  and 
particularly  in  permanent  mechanical  hypenemia,  the  vessels  in  the  liver, 
as  well  as  the  trunk  of  the  vena  portse,  and  the  branches  from  which  it 
arises,  are  found  dilated  and  varicose. 

Habitual  hyperaemia  of  the  liver  is  apt  to  be  followed  by  hypertrophy ; 
and  as  a  consequence  of  an  increased  production  of  portal  blood,  and  an 
exaggeration  of  its  peculiar  qualities,  the  nutmeg-liver  may  result,  which 
again,  may  give  rise  to  granular  degeneration  of  the  organ. 

Apoplexy  of  the  liver  is  a  very  rare  occurrence ;  it  results  from  con- 
gestion which  has  rapidly  attained  a  very  high  degree,  and  undoubtedly 
commences  as  capillary  hemorrhage  ;  an  apoplectic  spot  is  thus  caused, 


106  ABNORMITIES    OF 

which  may  enlarge  and  induce  a  rupture  of  larger  vessels.  According 
to  the  seat  of  the  hemorrhage  we  find  two  varieties,  viz.,  peripheral  or 
deep-seated  hemorrhage  ;  both  may  however  occur  simultaneously.  In 
the  former,  the  hepatic  peritoneum,  especially  that  investing  the  convex 
surface  of  the  right  lobe,  is  detached  in  a  varying  extent,  and  under- 
neath it  is  found  fluid  or  coagulated  blood  to  a  larger  or  smaller  amount. 
These  hemorrhages  occur  chiefly  in  infants,  as  a  consequence  of  impeded 
respiration  and  pulmonary  circulation,  from  suffocative  catarrh.  The 
hepatic  peritoneum  may  become  ruptured,  and  thus  cause  an  effusion  of 
blood  into  the  abdominal  cavity.  The  liver  is  in  a  state  of  permanent 
congestive  tumefaction,  and  being  overcharged  with  blood,  presents  a 
dark-red  color,  and  looseness  of  texture.  We  are  reminded  by  these 
effusions  of  the  analogous  bleedings  at  the  cranium,  accompanied  by  a 
detachment  of  either  the  pericranium  or  the  dura  mater,  which  consti- 
tute the  so-called  thrombus  or  cephalhgematoma. 

In  the  second  variety,  apoplectic  spots  of  various  forms  and  sizes  are 
found  in  the  parenchyma  ;  there  are  generally  several  of  them  dispersed 
through  the  organ.  This  variety  is  found  more  frequently  in  adults 
than  the  former,  but  the  two  may  take  place  at  the  same  time.  If  a 
cure  follows,  a  cellulo-fibrous  callous  cicatrix  remains. 

Anaemia  of  the  liver  is  the  result  of  hemorrhages,  exhaustion,  or  a 
reduction  of  the  mass  of  blood  by  extensive  exudative  processes,  and  is 
accompanied  by  a  diminution  of  the  consistency  of  the  liver.  It  is  also 
constantly  associated  with  many  hepatfo  diseases,  such  as  the  fatty,  the 
lardaceous,  and  waxy  liver,  to  which  we  have  already  adverted. 

b.  Inflammation  of  the  Liver  (Hepatitis). — Although  inflammation  of 
the  liver  may  not  be  a  very  rare  affection,  it  is  certain  that  the  intense 
degrees,  which  terminate  in  suppuration  and  abscess,  do  not  occur  very 
frequently  with  us.  We  may  remark  that  the  most  various  diseases  of 
the  hepatic  tissues  are  at  the  bedside  taken  for  hepatitis. 

If  we  sum  up  the  observations  of  solitary  instances  of  well-marked 
hepatitis,  taken  in  connection  with  the  condition  of  the  hepatic  tissue 
surrounding  wounds  and  recent  abscesses  of  the  liver,  we  find  the  fol- 
lowing to  be  the  anatomical  signs  of  hepatitis  previous  to  its  termination 
in  suppuration : 

Inflammation  never  attacks  the  entire  organ,  but  occurs  in  one  or 
more  patches.  Commonly  there  is  but  one  spot,  but  it  may  vary  in  ex- 
tent, and  the  process  is  here  found  developed  in  various  degrees.  The 
viscus  is  swollen  in  proportion  to  the  number  and  size  of  the  inflamma- 
tory patches,  and  this  tumefaction  is  particularly  perceptible  when  a 
section  is  made,  the  turgid  tissue  rising  above  the  edges  of  the  incision 
and  the  peritoneal  sheath.  The  parenchyma  is  loosened  and  lacerable, 
and  the  structure  becomes  more  apparent  from  the  enlargement  of  the 
acini,  which  gives  the  broken  surface  a  granular  appearance  ;  the  acini 
become  altered  in  shape,  and  assume  an  oval  form ;  their  circumference 
becomes  transparent,  so  that  each  acinus  seems  imbedded  in  a  gray  or 
grayish-red  layer  of  gelatinous  matter,  with  which  it  is  however  inti- 
mately blended.  In  the  advanced  stage  of  inflammation,  the  granulated 
structure  disappears,  the  tissue  seems  perfectly  uniform,  and  the  broken 
surface  has  a  laminated  appearance.  The  organ  has  a  paler  color,  and 


THE    LIVER.  107 

it  is  almost  uniformly  brown,  or  grayish-red  in  some  parts,  or  yellowish- 
red  or  pale-yellow  in  others.  The  capillary  vessels  are  filled  with  albu- 
minous and  fibrinous  coagula. 

If  the  process  extend  to  the  circumference,  the  peritoneal  investment 
becomes  opaque,  thickened,  and  is  easily  detached  ;  in  many  cases  it  is 
inflamed,  and  covered  by  an  exudation  of  varying  thickness. 

Acute  inflammation  frequently  leads  to  suppuration  of  the  parenchyma 
and  to  hepatic  phthisis.  We  then  find  small  spots  of  pus  occurring  here 
and  there  in  the  infiltrated  tissue,  which  gradually  increase,  coalesce, 
and  form  an  hepatic  abscess.  The  large  abscesses  found  in  the  dead 
subject  may  almost  always  be  proved  to  have  resulted  from  a  union  of 
several  smaller  spots,  by  the  remains  of  the  fistulous  passages  that  con- 
nected them,  by  the  sinuous  shape  of  their  circumference,  or  by  the 
debris  of  the  former  partitions. 

The  size  of  hepatic  abscesses  varies.  They  are  often  of  the  size  of  a 
fist,  or  a  child's  head,  and  may  even  occupy  an  entire  lobe. 

The  seat  of  the  abscess  corresponds  with  the  seat  of  the  previous  in- 
flammation ;  it  therefore  most  commonly  occupies  the  right  lobe,  is  gene- 
rally found  in  the  deeper  parenchyma,  and  is  often  accompanied  by  an 
abscess  in  the  left  lobe,  or  extends  into  the  latter. 

The  recent  abscess  represents  an  irregular  cavity  with  uneven  parietes, 
which  are  infiltrated  with  pus  and  consequently  very  friable ;  prolonga- 
tions of  the  same  tissue  project  into  the  cavity. 

The  abscess  increases  by  fusion  of  the  adjoining  tissue,  and  thus  as- 
sumes a  round  form,  which  becomes  sinuous  if  a  communication  is  esta- 
blished with  other  abscesses. 

When  the  suppurative  process  has  reached  the  boundary  of  the  original 
inflammation,  it  meets,  if  no  further  inflammatory  reaction  is  established 
in  the  vicinity,  with  infiltrated,  tumid,  and  discolored  parenchyma.  In 
this  manner  the  abscess  may  remain  passive  for  a  considerable  period, 
retaining  the  shape  and  other  characters  above  described.  It  is  com- 
monly lined  by  a  suppurating  and  loosely-attached  membrane.  In  refe- 
rence to  its  contents,  the  hepatic  abscess  presents  considerable  differences 
at  different  periods,  depending  in  part  upon  the  communication  established 
with  the  biliary  vessels.  The  pus  contained  in  the  recent  abscess  is  mixed 
with  little  or  no  bile,  as  the  acini  and  the  capillary  gall-ducts  have  be- 
come obliterated  by  the  inflammation ;  the  bile  contained  in  them  at  the 
commencement  of  the  inflammatory  attack,  is  at  most  found  in  combina- 
tion with  the  pus.  A  large  abscess  of  long  standing,  invariably  contains 
pus  mixed  with  a  considerable  amount  of  bile,  which  arises  from  the  com- 
munication established  between  the  cavity  and  larger  gall-ducts.  These 
are,  like  the  bronchi,  affected  by  a  continuation  of  the  suppurative  process, 
and  are  generally  eaten  across  in  a  transverse  or  slanting  direction ;  and 
in  exceptional  cases  only,  and  in  very  large  abscesses,  are  they  attacked 
and  opened  laterally.  The  pus  contained  in  old  abscesses  is  always  dis- 
colored, generally  greenish,  and  possessing  a  strong  ammoniacal  odor : 
we  must  undoubtedly  attribute  to  it  the  extensive  discoloration  of  the 
surrounding  parenchyma.  The  bloodvessels  opening  into  the  abscess  are 
blocked  up,  so  that  hemorrhage  very  rarely  occurs. 

Before  a  fatal  issue  takes  place,  the  hepatic  abscess  may  discharge  its 


108  ABNORMITIES    OF 

contents  in  different  directions,  and  with  various  results.  The  dis- 
charge is  very  rarely  effected  into  the  peritoneal  sac,  as  from  the  perito- 
neal investment  having  been  either  primarily  or  secondarily  involved  in 
the  inflammatory  process,  adhesions  will  have  been  formed,  which  pre- 
vent this  occurrence.  We  have  to  notice  the.  following  modes  of  dis- 
charge : 

a.  The  hepatic  abscess  induces  suppuration  in  and  between  the  thoracic 
and  abdominal  parietes,  and  after  a  communication  has  been  established 
between  the  former  and  the  superficial  abscess,  it  discharges  externally 
by  straight  or  sinuous,  narrow  or  wide  passages ;  and  by  this  means  a 
cure  is  sometimes  brought  about. 

/5.  The  diaphragm  may  be  perforated,  and  a  discharge  be  effected  into 
the  right  pleura,  where,  sooner  or  later,  fatal  inflammation  is  set  up ;  or 
if  the  lung  had  previously  been  agglutinated  to  the  diaphragm,  suppura- 
tion of  the  pulmonary  lamina  of  the  pleura  follows,  and  an  opening  being 
effected  into  the  bronchi,  pneumonia  and  pulmonary  abscess  supervene. 

Y.  The  hepatic  pus  may  be  eliminated  by  the  bronchi. 

d.  The  contents  of  the  abscess  may  be  discharged  into  the  stomach, 
the  duodenum,  and  the  colon ;  and  in  these  cases  the  hepatic  abscess  is 
reported  to  have  healed. 

e.  A  discharge  may  take  place  into  the  gall-bladder,  or  more  frequently 
into  one  of  the  larger  branches  of  the  hepatic  duct,  the  hepatic  pus  is 
conveyed  to  the  intestine  by  a  longer  passage,  and  thus  escapes. 

C.  Cases  in  which  the  central  aponeurosis  of  the  diaphragm  is  perfo- 
rated, and  the  pus  discharged  by  longer  or  shorter  sinuses  into  the  peri- 
cardium, inducing  pericarditis,  are  very  rare.  They  have  been  observed 
by  Smith  and  Graves,  and  once  by  ourselves. 

7).  Finally,  very  rare  cases  have  occurred  in  which  the  hepatic  abscess 
has  discharged  itself  into  large  vessels,  such  as  the  vena  cava ;  we  have 
observed  a  case  in  which  a  communication  was  established  between  an 
hepatic  abscess  and  the  vena  portse  and  duodenum. 

A  cure  of  the  hepatic  abscess  is  effected  after  the  pus  has  been  dis- 
charged by  one  of  the  above-described  methods,  or  it  may  result  without 
this  occurrence  from  more  or  less  complete  absorption  of  the  pus  by  the 
cellulo-vascular  membrane  investing  the  sides  of  the  abscess ;  for,  as  soon 
as  that  portion  of  the  parenchyma  which  has  undergone  purulent  infiltra- 
tion is  entirely  broken  down,  the  abscess  comes  in  contact  with  a  surface 
of  tissue  which  is  in  a  less  inflamed  state,  or  which  does  not  put  on  any 
reaction  till  now.  This,  however,  gives  rise  to  an  exudation,  which  in- 
vests the  smoothed  surfaces  of  the  abscess,  and  after  being  repeatedly 
redissolved,  at  last  forms  a  permanent  coating.  The  subjacent  layer  in 
the  interim  has  been  converted  into  fibro-cellular  tissue,  and  the  cellulo- 
vascular  investment  becoming  incorporated  with  the  former,  induces  a 
gradual  absorption  of  the  enclosed  pus,  the  walls  of  the  abscess  gradually 
approach  one  another,  and  at  last  unite  to  form  a  callous  cicatrix.  Not 
unfrequently  a  remnant  of  pus,  which  is  converted  into  a  cheesy  concre- 
tion, and  gradually  becomes  cretified,  may  still  be  found  locked  up  in  the 
tissue  of  the  cicatrix ;  the  parenchyma,  lying  above  the  situation  of  the 
original  abscess,  is  found  collapsed ;  and  if  the  abscess  extended  to  the 


THE    LIVER.  109 

circumference,  the  hepatic  peritoneal  lamina  forms  a  cicatrized,  dense, 
shrivelled  covering. 

The  true  glandular  tissue  of  the  acini,  and  the  interlobular  tissue,  are 
undoubtedly  to  be  considered  as  the  seat  of  the  inflammation  we  have 
just  examined ;  it  must  be  carefully  distinguished  from  inflammation  of 
the  capillary  gall-ducts,  as  well  as  from  abscess  resulting  from  suppura- 
tion in  the  latter,  which  is  characterized  by  its  large  admixture  of  bile. 
We  shall  advert  to  this  form  in  connection  with  diseases  of  the  gall- 
ducts. 

In  the  same  manner  we  have  to  distinguish  between  the  hepatic  abscess 
above  described,  and  secondary  or  metastatic  purulent  deposits. 

Induration  and  obliteration  of  the  hepatic  parenchyma  are  the  more 
frequent  result  of  slight  and  chronic  inflammatory  attacks.  The  product 
of  inflammation  solidifies,  and  the  hepatic  parenchyma  becoming  oblite- 
rated, is  converted  into  a  cellulo-fibrous  callosity,  which  gradually  con- 
tracts, and  induces  a  collapse  at  the  surface  of  the  liver  proportionate 
to  its  vicinity  to  the  surface.  If  this  occurs  simultaneously  at  several 
points,  the  surface  of  the  organ  obtains  an  uneven,  undulated,  and 
slightly  lobulated  appearance.  These  accumulations  of  cartilaginous 
tissue  are  to  be  distinguished  from  the  obliterations  and  atrophy  which 
affect  the  hepatic  tissue,  as  a  result  of  obliteration  of  the  portal  ramifica- 
tions consequent  upon  phlebitis. 

The  investigation  of  true  chronic  inflammation  of  the  liver  offers  still 
greater  difficulty,  inasmuch  as,  in  the  dead  subject,  we  generally  have  to 
deal  with  its  products  only,  in  various  degrees  of  development ;  many 
cases  of  the  so-called  granular  liver  are  probably  referable  to  this  head. 
At  the  bedside,  the  most  heterogeneous  conditions  when  accompanied  by 
tedious  and  oppressive  morbid  sensations  and  by  painful  symptoms,  espe- 
cially by  enlargement,  are  diagnosed  as  chronic  inflammation  of  the  liver. 

c.  Inflammation  of  the  vena  portce. — This  is,  under  all  circumstances, 
a  very  important  affection.  It  occurs  both  in  a  primary  and  in  a  secon- 
dary form,  and  may  in  either  lead  to  obliteration  or  suppuration,  and 
may  attack  the  trunk  and  the  ramifications  of  the  vessel,  or  the  latter 
only. 

Inflammation  ending  in  obliteration  of  the  branches  of  the  vena  portae 
within  the  liver  demands  a  special  notice,  as  it  occurs  very  frequently, 
although  we  rarely  have  opportunities  of  investigating  it  in  the  dead  sub- 
ject otherwise  than  in  its  termination  and  its  consequences.  It  would 
appear  to  be  owing  to  an  anomalous  condition  of  the  portal  blood,  and 
to  belong  to  the  adhesive  form.  Several  cases  that  we  have  observed, 
in  which  irregular  anastomoses  were  discovered  between  the  portal  and 
the  general  venous  system,  by  means  of  the  patulous  umbilical  vein,  seem 
to  authorize  this  view. 

Under  certain  indented  and  contracted  parts  of  the  surface  of  the 
liver,  we  discover  an  accumulation  of  cellulo-fibrous  callous  tissue,  which, 
on*more  minute  examination,  is  found  to  conduct  to  a  larger  or  smaller 
portal  branch,  with  which  it  is  connected.  The  vessel  itself  is  converted 
into  a  ligamentous  cord,  or  it  is  plugged  up  with  a  fibrinous,  cheesy,  or 
calcareous  deposit. 

The  consequences  of  the  obliteration  are,  atrophy  of  that  part  of  the 


110  ABNORMITIES    OF 

\ 

liver  which  is  supplied  by  the  ramifications  of  the  vessel,  lobulation  of  the 
liver,  as  described  at  page  103,  and  in  extreme  cases,  ascites. 

d.  Deposits,  metastases  in  the   liver. — Metastases  occur  in  the  liver 
under  the  same  conditions  under  which  they  take  place  in  the  lungs. 
They  are,  however,  much  less  frequent  in  the  former  than  in  the  latter 
and  in  the  spleen ;  and   the  so-called  hepatic  abscess,  more  especially 
consequent  upon  important  surgical  operations,  wounds  and  injuries  of 
the  cranium,  is  found  much  more  rarely  than  has  been  hitherto  supposed. 
Besides,  we  always  simultaneously  discover  deposits  in  other  organs,  par- 
ticularly in  the  lungs  and  the  spleen.     We  are  unacquainted  with  the 
special  conditions  which  give  rise  to  a  predominant   deposit  in  the  liver, 
with  the  exception  of  those  cases  in  which  the  source  of  the  poisoning  of 
the  blood  is  within  the  compass  of  the  portal  system. 

The  deposit  in  the  liver  is  also  caused  by  the  deposition  or  exudation 
of  fibrin  through  the  coats  of  the  capillaries  into  the  tissue,  or  by  the 
coagulation  of  the  blood  in  the  capillary  rete  of  vessels.  In  both  cases 
metamorphoses  may  ensue  which  vary  according  to  the  nature  of  the 
morbid  essence  absorbed  into  the  blood ;  occasional  induration  and  shrivel- 
ling are  induced,  with  consequent  obliteration  of  the  parenchyma  and 
the  capillaries ;  more  frequently  purulent  or  ichorous  fusion  result,  and 
then  either  suppurative  inflammation  of  the  surrounding  parenchyma  is 
established,  or  a  solution  of  the  coats  of  the  capillary  vessels  is  effected. 

The  deposit  presents,  as  in  the  lungs,  the  appearance  of  a  circum- 
scribed nodulated  accumulation,  of  a  dark-red  or  brownish-red  color, 
which,  as  it  approaches  the  state  of  fusion,  is  converted  into  a  dirty  yellow 
or  greenish  color. 

The  deposit  has  a  rounded  form,  varying  in  size  from  that  of  a  pea  to 
that  of  a  walnut ;  it  is  found  in  considerable  numbers,  and  is  commonly 
seated  in  the  peripheral  layer,  where  it  gives  rise  to  inflammation  of  the 
hepatic  peritoneal  lamina.  This  is  a  guide  to  distinguish  it  from  the  ab- 
scess which  originates  in  idiopathic  inflammation  of  the  liver;  the  diag- 
nosis is  also  aided  by  the  acute  course  of  the  affection,  by  its  origi- 
nating in  another  morbid  affection,  by  the  typhoid  symptoms,  by  the 
occurrence  of  similar  processes  in  other  organs,  more  especially  in  the 
lungs  and  the  spleen,  by  the  disorganization  of  the  blood,  and  the  re- 
sulting jaundice. 

e.  G-angrene  of  the  liver. — Gangrene  of  the  liver  is  very  rare,  in  fact 
Ferrers  and  B£rard  deny  its  occurrence,  but  we  have  seen  it  in  one 
well-marked  case,  associated  with  pulmonary  gangrene.     It  is  developed 
in  parts  affected  with  inflammation  and  suppuration,  not  so  much  as  a 
result  of  intense  inflammation  as  of  certain  peculiar  conditions,  which 
cause  a  tendency  to  gangrenous  degeneration.     It  occurs  in  more  or  less 
circumscribed  spots,  in  which  the  parenchyma  is  dissolved  into  a  brown 
or  greenish-black  pulp,  which  diffuses  the  characteristic  odor  of  sphacelus. 
We  find  suppuration  in  the  vicinity,  which  is  the  product  of  reactive 
inflammation,  and  which  defines  the  boundaries  of  the  mortified  part.* 

/.  Granular  liver. — Granular  liver  is  one  of  the  most  important,  though 
in  many  respects,  and  especially  in  reference  to  its  pathogeny,  one  of 
the  most  enigmatical  affections  of  the  liver ;  it  is  termed  by  Laenncc 
cirrhosis  :  older  authors  have  considered  it  identical  with  or  related  to 


THE    LIVER.  Ill 

scirrhus  ;  and  if  viewed  in  reference  to  its  termination  only,  it  may  be 
called  induration  of  the  liver. 

It  undoubtedly  presents  many  degrees,  which  merge  into  one  another  ; 
from  the  very  unsatisfactory  state  of  our  knowledge,  however,  in  refer- 
ence to  the  elementary  process  and  fundamental  nature  of  the  disease,  we 
consider  it  necessary  to  sketch  the  affection  as  seen  in  a  marked  case, 
without  any  further  complication,  and  subsequently  to  state  what  is  known 
of  the  earlier  stages  of  the  disease,  and  of  the  later  metamorphoses  of 
the  organ. 

In  a  case  of  the  kind  alluded  to,  the  yiscus  appears  considerably  dimi- 
nished in  size,  and  this  decrease  is  accompanied  by  a  characteristic  change 
of  form.  The  margins  are  thinned  down  to  such  a  degree,  as  to  repre- 
sent a  cellulo-fibrous  seam,  which  is  folded  upon  the  remainder  of  the 
organ ;  the  vertical  diameter  of  the  liver  has  increased,  and  is  found  to 
consist  chiefly  of  the  hemispherical  or  globular  right  lobe.  (Vide  p.  103.) 

The  external  surface  presents  a  granular,  warty,  racemose  appearance, 
-which  results  from  the  projection  of  the  peripheral  so-called  granulations, 
of  the  liver.  These  granulations  may  all  have  the  same  size,  e.  g.  that 
of  a  hemp-seed,  and  the  surface  then  is  uniformly  racemose :  or  they 
vary  in  size,  and  the  surface  is  then  unevenly  racemose. 

The  hepatic  surface  intervening  between  the  granulations  is  of  a  dull 
white  color,  tendinous,  shrivelled,  and  contracted ;  the  granulations  are 
thus  circumscribed,  separated  from  one  another,  and  even  occasionally 
pediculated. 

The  viscus,  when  it  has  this  appearance,  is  to  a  certain  extent  elastic 
and  tough,  and  even  indurated,  so  as  to  offer  a  cartilaginous  resiliency ; 
it  cannot  be  broken,  as  it  possesses  the  tenacity  of  leather. 

The  scalpel  itself  confirms  the  fact  of  induration,  as  the  instrument 
meets  with  a  scirrhoid  substance,  which  may  even  cause  a  crunching 
sound. 

A  section  shows  the  above-mentioned  granulations  to  be  either  isolated 
or  grouped  together  ;  an  accumulation  of  dirty  white,  dense,  resilient  cel- 
lular tissue,  which  is  almost  destitute  of  bloodvessels,  and  which  forms  a 
nidus  for  the  former,  is  seen  between  them. 

The  color  of  the  organ  is  variously  modified  ;  being  dependent  upon 
the  color,  either  of  the  granulations,  which  we  shall  have  still  further  to 
examine,  or  of  the  intervening  fibro-cellular  tissue. 

The  liver  is  frequently  attached  to  adjacent  parts,  especially  to  the 
diaphragm,  by  means  of  cords  or  laminae  of  new  matter;  the  adjoining 
peritoneum,  and  especially  the  peritoneal  covering  of  the  gall-bladder, 
and  the  folds  which  leave  the  liver,  are  opaque,  shrivelled,  and  tendinous. 

The  granulations  have  given  rise  to  the  name  of  granular  liver ;  and 
from  the  coexisting  atrophy  and  diminution  of  size,  the  affection  is  also 
termed  granular  atrophy  of  the  liver. 

The  granulations  are  the  most  prominent  sign  in  the  sketch  we  have 
given,  and  the  question  arises  as  to  their  nature. 

Laennec  viewed  the  granulations  as  an  adventitious  product,  and  as 
his  specimens  offered  a  yellow  color,  he  termed  it  cirrhosis  (xtpfos,  fulvus). 

One  may  easily  be  convinced  of  the  incorrectness  of  this  view,  as  a 


112  ABNORMITIES    OF 

careful  examination  at  once  proves  that  the  granulations  consist  of  no- 
thing but  hepatic  parenchyma,  which,  however,  as  we  shall  subsequently 
have  occasion  to  show,  is  variously  modified. 

It  follows  from  our  demonstration  that  in  granular  liver  the  hepatic 
parenchyma  has  become  reduced  to  the  granulations,  and  that  the  por- 
tion which  has  disappeared,  has  been  replaced  by  fibro-cellular  tissue. 

The  desire  to  obtain  more  accurate  views  as  to  the  nature  of  the  granu- 
lations and  their  mode  of  origin,  has  caused  the  promulgation  of  various 
doctrines  which  are  untenable  or  incomprehensive  in  proportion  as  their 
authors  attached  too  much  importance  to  the  ideas  of  hypertrophy  and 
atrophy  and  their  combination,  or  attempted  to  construct  a  theory  from 
isolated  observations,  or  because  they  did  not  sufficiently  distinguish  be- 
tween the  diseases  of  the  hepatic  parenchyma  preceding  the  formation  of 
granulations,  and  those  affecting  the  granulations  themselves,  and  other 
morbid  conditions  not  essentially  connected  with  them. 

According  to  Bouillaud,  with  whom  Andral  coincides  in  the  main,  the 
granulations  are  the  result  of  hypertrophic  development  of  the  so-called 
white  or  secreting  substance,  accompanied  by  obliteration  and  gradual 
atrophy  of  the  red  or  vascular  tissue. 

Cruveilhier  advocates  a  different  opinion.  He  thinks  that  cirrhosis 
consists  in  the  atrophy  of  a  considerable  number  of  the  hepatic  acini, 
accompanied  by  hypertrophy  of  the  remainder,  which,  as  it  were,  take 
the  place  of  the  former. 

We  pass  over  the  unsatisfactory  and  erroneous  doctrines  of  other 
writers,  which  are  based  upon  investigations  of  solitary  cases,  or  of  ano- 
malies in  the  elementary  tissue,  and  merely  remark,  that  we  do  not  adopt 
any  one  of  the  above  views  exclusively,  as  they  do  not  appear  to  us  to 
embrace  the  entire  characters  of  granular  liver. 

Granular  liver  presents  considerable  varieties.  The  granulations 
themselves  offer  numerous  variations  in  reference  to  texture,  number, 
size  and  form. 

With  regard  to  their  texture,  we  sometimes  find  that  they  consist  of 
normal,  or  at  least  tolerably  normal,  hepatic  parenchyma.  Commonly, 
however,  this  is  not  the  case  ;  the  parenchyma  of  the  granulations  is  itself 
abnormal,  and  variously  diseased ;  such  cases  render  the  analysis  of  the 
hepatic  granulations  difficult,  and  cause  errors  in  the  conclusions  arrived 
at,  as  not  sufficient  attention  is  paid  to  the  distinction  between  the 
essential  and  non-essential  characters  of  the  abnormity.  The  altera- 
tions of  tissue  in  the  granulations  are  either  such  as  constitute  the  causa 
proximo,  of  the  entire  metamorphosis,  i.  e.  they  are  essential,  or  they 
are  mere  accidental  complications,  which  may  either  precede  or  accom- 
pany the  formation  of  granulations.  As  we  shall  subsequently  have  to 
show  the  development  of  the  granulations  from  the  former,  and  as  we 
are  also  compelled  to  examine  into  the  complications  of  granular  liver, 
we  here  give  a  summary  of  the  abnormal  conditions,  without  reference 
to  the  above  distinctions. 

Firstly.  The  parenchyma  of  the  hepatic  granulations  occasionally  pre- 
sents a  coarse-grained  hypertrophy  of  the  acini,  the  granulations  pro- 


THE    LIVER.  113 

jecting  on  a  sectional  surface  in  the  shape  of  dark  reddish-brown  and 
elastic  points. 

Secondly.  It  frequently  appears  in  the  various  degrees  of  the  nutmeg 
liver  (Laennec's  cirrhosis  of  a  low  degree). 

Thirdly.  The  granulations  appear  in  the  shape  of  rounded  or  lobular 
convolutions  of  dilated,  turgid,  yellow,  gall-ducts,  the  red  vascular  sub- 
stance in  the  vicinity  having  disappeared.  This  yields  one  of  the  com- 
monest and  most  exquisite  forms  of  the  granular  liver  ;  it  is  genuine 
cirrhosis,  which  originates  in  the  first  variety  of  the  nutmeg-liver,  de- 
pendent upon  stasis  and  dilatation  of  the  biliary  ducts.  The  majority 
of  authors  have  evidently  taken  their  description  of  granular  liver  from 
specimens  of  this  kind. 

Fourthly.  The  parenchyma  of  the  granulations  is  frequently  infiltrated 
with  fatty  matter  or  similar  products,  and  the  granulation  then  presents 
on  a  small  scale  all  the  signs  discussed  at  page  98.  Gluge  has  evidently 
employed  a  specimen  of  this  description  for  his  investigations. 

Fifthly.  We  occasionally  find  the  granulations  in  the  condition  of 
what  we  have  termed  yellow  acute  atrophy ;  they  are  then  yellow  through- 
out, and  appear  at  the  surface  and  on  section  as  pulpy,  collapsed, 
friable,  yellow  masses. 

Sixthly.  The  parenchyma  of  the  hepatic  granulations  frequently  pre- 
sents symptoms  of  an  inflammatory  condition ;  it  then  appears  pale,  of 
a  homogeneous  structure,  with  obstruction  of  the  small  biliary  canali- 
culi,  commencing  induration  and  obliteration. 

The  granulations  vary  much  as  to  number,  and  are  either  uniformly 
distributed  through  the  surrounding  cellulo-fibrous  tissue,  or  they  coa- 
lesce into  groups  of  various  extent.  The  more  numerous  they  are,  the 
less  the  hepatic  parenchyma  is  destroyed ;  the  number  of  the  granula- 
tions therefore  indicates  the  degree  of  atrophy  that  has  taken  place, 
and,  if  we  take  the  quality  and  quantity  of  the  textural  changes  into 
consideration,  the  stage  of  the  disease  generally. 

The  size  of  the  granulations  varies  from  that  of  a  pin's  head  to  that  of 
a  horse-bean,  according  as  a  single  acinus,  or  an  entire  lobule,  or  a  large 
portion  of  the  organ  is  affected ;  they  are  generally  of  a  rounded  form, 
though  they  are  very  frequently  of  an  irregular  and  especially  of  a  lobu- 
lated  shape.  In  the  majority  of  instances  we  find  one  size  and  form  to 
prevail. 

The  cellulo-fibrous  tissue  intervening  between  the  granulations,  is 
either  diminished  or  increased  in  amount.  There  is  generally  an  inverse 
ratio  between  this  tissue  and  the  number  of  granulations ;  but  we  find 
exceptional  cases  in  which  the  granulations  are  very  numerous,  and  the 
interstitial  cellular  tissue  is  also  much  increased.  The  latter  varies  much 
as  to  density,  resiliency,  vascularity,  succulence,  and  color.  Sometimes 
it  is  loose,  friable,  vascular,  more  or  less  reddened,  and  succulent ;  at 
other  times  it  is  tough,  less  succulent,  of  a  dirty  gray  or  greenish  color, 
at  others  again,  dense,  indurated,  dirty  white,  of  fibro-cartilaginous, 
scirrhoid,  resiliency  and  elasticity,  crepitating  when  cut,  &c. 

Having  discussed  the  two  constituent  parts  of  granular  liver,  we  must 
now  examine  into  the  origin  of  the  metamorphosis. 

We  have  seen  that  in  granular  liver  the  granulations  represent  the 

VOL.  II.  8 


114  ABNORMITIES    OF 

persistent  hepatic  tissue,  and  that  the  parenchyma  which  has  been  re- 
moved is  replaced  by  cellulo-fibrous  tissue.  The  question  arises  whether 
this  reduction  is  primary  or  secondary,  and  supposing  the  latter  case, 
which  is  the  primary  anomaly  ?  It  is  commonly  set  down  as  mere 
atrophy,  in  consonance  with  the  view  of  the  French  observers  above 
quoted. 

We  are  not  of  opinion  that  granular  liver  always  takes  its  origin  in 
the  same  fundamental  affection ;  we  are  inclined  to  adopt  two  morbid 
states  as  the  essential  and  original  anomalies,  which  give  rise  to  granu- 
lations in  the  hepatic  parenchyma  as  a  secondary  affection. 

a.  In  one  case  there  is  a  morbid  development  of  the  capillary  gall- 
ducts  (the  so-called  secreting  tissue) ;  an  accumulation  of  the  secretion, 
and  probably  also  a  hypertrophy  of  the  parietes  of  those  vessels  giving 
rise  to  the  nutmeg  liver,  and  to  an  obliteration  of  the  capillary  blood- 
vessels, the  so-called  vascular  substance.  We  then  have  to  do  with  the 
gradual  reduction  of  the  organ,  already  described  under  the  head  of 
Atrophy,  as  an  advanced  stage  of  cirrhosis ;  in  this  condition  granular 
liver  takes  its  origin,  for  the  granulations  are  formed  by  the  biliary 
ducts  coalescing  into  rounded  fasciculi  or  coils  of  the  size  of  a  pin's  head 
or  hemp-seed.  They  are  more  or  less  of  a  yellow  color,  containing  fat, 
and  either  solitary  or  collected  into  lobular  groups  ;  they  are  surrounded 
by  a  spongy,  cellular,  soft,  succulent,  red,  and  vascular  tissue,  from  which 
they  can  only  be  separated  by  rupture  of  the  latter  and  of  its  vessels. 
This  anomaly  is  commonly  met  with  in  *  various  degrees  of  development 
at  different  parts  of  the  viscus ;  it  is  generally  more  advanced  in  the 
peripheral  portions,  the  deeper  portions  presenting  at  the  same  time  the 
appearance  of  the  nutmeg  degeneration  ;  the  liver  is  frequently  enlarged, 
but  certainly  not  diminished  in  size,  and  preserves  the  thick,  massive 
edges  peculiar  to  the  nutmeg  liver. 

A  secondary  metamorphosis  now  gradually  supervenes,  the  stage  of 
obliteration  and  atrophy.  The  interstitial  tissue  gradually  loses  its 
vascularity,  its  red  color,  succulence,  and  spongy  texture  ;  it  becomes 
more  and  more  pale,  of  a  grayish-red,  and  dirty  white  color  ;  it  shrivels 
up,  and  becomes  denser  and  drier,  coriaceous,  and  even  of  scirrhoid 
hardness  ;  and  it  presents  a  cellulo-fibrous,  fibro-cartilaginous  structure. 
The  granulations  at  the  same  time  undergo  important  modifications. 
The  obliteration  of  the  interstitial  tissue  not  only  destroys  the  vascular 
connection  between  the  latter  and  the  granulations,  but,  as  their  nutri- 
tion becomes  impaired,  their  secreting  power  also  ceases.  We  now  find 
the  granulation  enclosed  in  a  cellulo-fibrous  case,  from  which  it  may  be 
easily  removed,  as  it  is  only  connected  with  its  investment  by  a  few  de- 
licate cellular  threads,  or  is  even  quite  detached,  with  the  exception  of  a 
single  vascular  pedicle ;  it  is  found  collapsed,  pulpy,  of  a  dirty  yellow 
color  ;  it  gradually  diminishes  in  size,  the  surrounding  tissue  also  becom- 
ing atrophied ;  it  soon  appears  only  as  a  minute  yellow  or  greenish  spot, 
and  at  last  vanishes  entirely.  In  exceptional  cases,  in  which  the  liver 
has  become  so  much  indurated  as  to  be  incapable  of  further  condensa- 
tion, the  tissue  surrounding  the  individual  granulations  is  converted  into 
a  cyst  with  a  serous  lining,  in  which  the  granule  floats,  attached  only  by  a 
vascular  footstalk,  and  surrounded  by  a  yellowish  or  pale  green,  watery, 


THE    LIVER.  115 

or  gelatinous  fluid.  In  consequence  of  the  vascular  obliteration,  it  is 
gradually  so  much  reduced  as  at  last  to  present  nothing  but  a  minute 
nodule  attached  to  the  internal  surface  of  the  cyst,  which  is  now  entirely 
filled  with  the  fluid. 

In  this  variety,  therefore,  the  original  anomaly  consists  in  the  hepatic 
parenchyma  being  gradually  reduced  to  the  capillary  gall-ducts  which 
have  assumed  the  shape  of  the  granulations  ;  and  in  so  far  as  this  is 
genuine  cirrhosis  of  the  liver,  it  certainly  bears  some  resemblance  to  the 
pulmonary  cirrhosis  described  by  Corrigan.  The  secondary  metamor- 
phosis causes  a  gradual  atrophy  of  the  granulations,  accompanied  by  a 
predominance  of  the  interstitial  cellulo-fibrous  tissue,  and  a  uniform 
diminution  of  the  entire  organ. 

The  degree  attained  by  the  metamorphosis  is  proportionate  to  the 
number  of  obsolete  granulations,  or  to  the  amount  of  parenchyma  re- 
maining capable  of  performing  its  functions  ;  the  organ  decreases  in  pro- 
portion to  the  shrivelling  and  condensation  of  tha  interstitial,  cellulo- 
fibrous  tissue ;  and  it  often  appears  reduced  to  one-quarter,  or  even  one- 
sixth,  of  its  ordinary  size.  The  condensation  of  the  cellulo-fibrous 
tissue,  as  it  gives  rise  to  a  decrease  of  the  organ,  also  induces  a  corruga- 
tion and  shrivelling  of  the  peritoneal  investment.  The  latter  will  be 
more  or  less  opaque,  and  thickened ;  and,  being  retracted  between  the 
projecting  granulations,  these  not  unfrequently  appear  to  have  a  neck- 
like  contraction.  These  changes  in  the  hepatic  peritoneal  covering  take 
place  without  any  symptoms  of  inflammatory  action. 

The  secondary  metamorphosis  chiefly  affects  the  margin  of  the  liver, 
and  more  particularly  the  left  lobe.  The  organ  very  commonly  appears 
to  have  been  almost  or  entirely  deprived  of  parenchyma,  and  to  consist 
exclusively  of  fibro-cellular  tissue,  the  edges  more  particularly  being 
thinned  off  and  turned  back  upon  the  body  of  the  organ,  the  left  lobe  of 
which  is  converted  into  a  mere  appendix  of  fibro-cellular  structure,  of  the 
size  of  a  hen's  egg  or  a  walnut. 

Not  unfrequently  the  granulations  assume,  in  the  advanced  stages,  and 
after  a  long  duration  of  the  disease,  a  bluish  or  dark-green  color,  which 
particularly  affects  those  seated  at  the  concave  surface  of  the  liver. 

This  form  of  cirrhosis  of  the  liver  undoubtedly  originates  in  hypenemic 
states,  a  view  that  is  confirmed  by  their  frequent  connection  with 
organic  disease  of  the  heart :  its  frequent  occurrence  in  drunkards  also 
points  to  a  peculiar  anomaly  in  the  constitution  of  the  portal  blood. 

/5.  In  the  second  case,  the  original  affection  of  the  hepatic  parenchyma 
in  granular  liver  is  proved,  by  the  post-mortem  appearance  of  the  granu- 
lations, to  consist  in  a  slow  chronic  inflammation.  This  induces  a  gradual 
obliteration  of  the  parts  attacked,  and  their  conversion  into  fibro-cellular 
tissue,  the  amount  of  which  varies  in  proportion  as  the  processes  of  ab- 
sorption or  of  organization  predominate  in  the  inflammatory  product. 
This  secondary  metamorphosis,  from  not  occurring  uniformly,  results  in 
a  subdivision  of  the  organ  into  larger  or  smaller  scattered  compartments, 
which  present  the  characteristic  rounded  form  of  the  granulations  in  the 
same  ratio  as  they  correspond  to  single  hepatic  lobules.  Their  paren- 
chyma is  frequently  found  in  the  original  state  of  chronic  inflammation, 


116  ABNORMITIES    OF 

but  it  may  be  unchanged,  or  it  may  offer  one  of  the  other  accidental  ano- 
malies alluded  to. 

It  is  intelligible  that  the  diminution  of  size  in  this  variety  is  often  in- 
considerable, that  the  organ  may  even  be  enlarged,  and  that  the  fibro- 
cellular  tissue  is  accumulated  in  such  a  manner  as  to  preponderate  over 
the  parenchymatous  cellular  tissue.  A  marked  decrease  of  size  occurs 
when  the  obliteration  is  extensive  and  the  cellule-fibrous  tissue  has 
shrunk ;  and  as  this  decrease  advances,  the  pressure  exerted  by  the  shri- 
velled tissue  upon  the  parts  not  originally  affected  by  the  anomaly,  in- 
duces an  atrophy  in  them ;  they  fade,  and  put  on  a  rusty  or  dark  yellow 
color. 

Granular  liver  frequently  presents  an  abnormity  which  appears  peculiar 
to  this  variety.  We  allude  to  the  presence  on  the  condensed  peritoneal 
investment  of  pseudo-membranous  formations,  of  a  cellular  or  cellulo- 
fibrous  texture,  which  generally  extend  to  the  diaphragm  in  the  shape 
of  corded  adhesions.  They  are  the  result  of  inflammatory  processes, 
which  have  become  extinct  long  before  the  occurrence  of  the  secondary 
metamorphosis,  and  which  appear  to  afford  evidence  of  the  inflammatory 
nature  of  the  hepatic  disease  itself. 

Besides  these  two  modes  of  development  of  granular  liver,  the  affec- 
tion may  also  be  viewed  as  a  retrograde  process,  manifested  in  deposi- 
tions or  infiltrations  of  the  hepatic  parenchyma,  arising  from  an  anoma- 
lous state  of  the  blood. 

In  reference  to  the  external  conformation  of  granular  liver,  we  have 
still  to  advert  to  a  variety  which  is  characterized  by  the  hepatic  paren- 
chyma not  being  reduced  to  granulations,  but  continuing  in  large  masses, 
the  more  superficial  of  which  are  pushed  out  by  the  shrinking  interstitial 
tissue,  and  being  more  or  less  contracted  at  their  base,  cause  the  entire 
organ  to  appear  lobulated. 

Granular  disease  of  the  liver  is  found  complicated  with  all  the  essential 
or  accidental  anomalies  which  we  have  described  as  occurring  in  the 
paranchyma  of  the  granulations,  and  these  anomalies  may  either  precede 
the  granular  disease  or  supervene  after  its  development.  The  complica- 
tions may  be  hypertrophy,  nutmeg  liver,  cirrhosis,  adipose  and  other  in- 
filtrations, acute  yellow  atrophy,  inflammatory  and  other  hepatic  diseases. 
The  granular  disease  arising  from  one  of  the  essential  anomalies,  e.  g. 
from  inflammatory  causes,  is  more  particularly  liable  to  combine  with 
another  essential  anomaly,  as,  for  instance,  with  true  cirrhosis. 

The  complication  with  adipose  deposit  is  peculiarly  interesting.  The 
latter  may, — 

Firstly,  be  the  primary  affection  upon  which  the  granular  disease  is 
grafted  in  the  shape  of  cirrhosis.  As  the  cirrhosis  advances,  the  reduc- 
tion of  the  organ  generally,  but  more  particularly  of  the  marginal  por- 
tions which  have  been  infiltrated  with  fat,  is  impeded,  and  the  atrophy 
that  does  take  place  is  characterized  by  its  affecting  the  margin  much 
less  than  in  the  uncomplicated  form. 

Secondly ;  the  adipose  deposit  may  supervene  upon  a  granular  state 
of  the  liver ;  and  if  it  does  so  before  the  secondary  metamorphosis  has 
advanced  very  far,  and  whilst  the  granulations  are  still  very  numerous, 
it  may  prevent  the  liver  from  assuming  the  form  peculiar  to  the  granular 


THE    LIVER.  117 

condition.  If  it  occurs  at  a  later  period,  it  need  not  modify  the  cha- 
racteristic form  of  the  organ. 

Thirdly ;  the  cirrhotic  and  shrinking  granulation  which  is  cut  off  by 
dense  cartilaginous  interstitial  tissue  may  degenerate  into  a  flabby,  dirty 
yellowish-brown  fat-lobule,  the  degeneration  apparently  proceeding  from 
the  confined  biliary  matter. 

A  similar  relation  exists  in  regard  to  the  modifications  of  form  be- 
tween the  granular  condition  and  other  infiltrations  of  the  hepatic  paren- 
chyma. 

Granular  liver  is  also  very  frequently  coincident  with  the  most  various 
morbid  affections  of  the  heart,  which  give  rise  to  congestion  in  the  vena 
cava  and  in  the  portal  system;  of  these,  hypertrophy,  dilatation,  and 
valvular  disease  are  the  most  common.  Disease  of  the  heart  must  be 
considered  as  an  important  momentum  in  the  origin  of  the  hepatic  dis- 
ease. 

The  symptoms  resulting  from  the  granular  state  of  the  liver  bear  a 
ratio  with  the  degree  of  its  development ;  the  impermeability  and  oblitera- 
tion of  its  secreting  tissue  induce,  on  the  one  hand,  congestion  in  the 
portal  system,  hyperaemic  states  of  the  intestine  and  of  the  peritoneum, 
a  blennorrhoic  condition  of  the  former,  tumefaction  of  its  membranes, 
and  ascites  ;  on  the  other,  dyscrasic  conditions  of  the  blood  allied  to 
scurvy  and  frequently  accompanied  by  icterus,  an  inclination  to  exuda- 
tive processes,  with  an  especial  proclivity  to  hemorrhage,  anasarca,  and 
anaemia. 

We  cannot  admit  that  the  relation  existing  between  Bright's  disease 
of  the  kidneys  and  granular  liver,  though  the  two  often  coexist,  has  been 
accounted  for.  In  one  set  of  cases  both  affections  would  seem  to  have 
originated  in  common  causes  ;  in  another,  Bright's  disease  is  evidently 
of  more  recent  date,  and  has  supervened  upon  the  existing  granular  state 
of  the  liver ;  but  whether  in  this  case  it  is  due  to  a  separate  cause,  or  is 
owing  to  the  dyscrasia  accompanying  the  hepatic  disease,  we  are  unable 
to  determine. 

Granular  liver  is  invariably  a  chronic  affection,  which  may  often  be 
arrested  in  its  development  for  a  short  time,  but  never  permanently.  It 
terminates  fatally  by  inducing  anaemia  and  tabes  complicated  with  dropsy ; 
by  disorganization  of  the  blood,  by  exhausting  and  paralyzing  exuda- 
tions on  the  serous  membranes,  and  especially  on  the  peritoneum.  It 
rarely  occurs  before  the  prime  of  life,  but  we  have  seen  one  case  of  it  at 
the  age  of  seventeen. 

g.  Adventitious  growths.  «.  Anomalous  production  of  fat. — This 
occurs  in  two  distinct  forms.  We  have  already  become  acquainted  with 
one  in  the  shape  of  adipose  deposition,  or  infiltration  of  the  hepatic  tissue 
with  free  fatty  matter ;  the  second  is  very  unusual,  and  appears  as  a 
lipomatous  morbid  growth  of  a  rounded  or  lobulated  form,  and  rarely 
larger  than  a  pea. 

/9.  Cavernous  tissue. — This  is  remarkable  from  its  frequent  occurrence 
in  the  liver.  It  resembles  the  tissue  of  the  corpora  cavernosa,  and  is 
commonly  found  in  the  peripheral  substance  of  the  liver  only ;  from  its 
dark-blue  color  it  shines  through  the  peritoneum,  and  the  affection  is 
therefore  recognized  on  the  external  examination  of  the  organ.  It  varies 


118  ABNORMITIES    OF 

in  size,  from  that  of  a  hemp-seed  or  pea  to  that  of  a  hen's  egg,  and 
more  ;  is  generally  irregular  in  form,  and  its  cells  contain  a  large  quan- 
tity of  dark  blood ;  a  connection  may  be  always  traced  between  the  latter 
and  some  larger  portal  vessel.  According  to  the  amount  of  blood  con- 
tained in  the  compartments,  these  are  found  in  the  dead  subject  project- 
ing beyond  the  surface  of  the  liver,  or  collapsed  and  sunk.  Sometimes 
they  are  single,  sometimes  numerous. 

Y.  Cysts. — The  liver  is  more  liable  to  the  formation  of  encysted  tumors 
than  any  other  parenchymatous  organ ;  and  we  repeat  that  the  rarity  of 
tubercular  deposit  in  the  liver  enhances  the  importance  of  the  hydatid 
theory.  We  find  in  the  liver — 

aa.  The  simple  serous  cyst,  a  serous  sac  containing  a  clear  watery  fluid  ; 
this  is  not  met  with  as  often  as 

PP.  The  acephalocyst  of  Laennec ;  which  in  the  first  instance  is  merely 
a  serous,  but  from  acquiring  a  fibrous  investment,  is  converted  into  a 
nbro-serous  sac,  containing,  besides  serum,  the  so-called  acephalocysts ; 
these  are  small  bladders  (hydatids),  formed  of  coagulated  albumen  and 
filled  with  an  albuminous  fluid ;  they  vary  in  size  and  number,  and  are 
either  attached  to  the  parietes  of  the  former  or  float  in  the  serum. 

The  acephalocyst  generally  attains  a  considerable  size  in  the  liver. 
We  have  several  extraordinary  specimens  in  the  Viennese  museum,  and 
there  is  one  of  a  foot  in  diameter.  In  proportion  as  the  heterologous 
growth  increases,  the  hepatic  parenchyma  gives  way,  and  the  nearer  the 
former  originally  was  to  the  surface,  the  sooner  will  it  reach  the  peritoneal 
investment;  it  then  projects  above  the*liver,  with  a  larger  or  smaller 
segment  of  its  circumference.  Under  these  circumstances  the  peritoneum 
invariably  inflames,  and  the  consequence  is  a  thickening  of  the  latter 
upon  and  in  the  vicinity  of  the  acephalocyst ;  an  investment  of  pseudo- 
membranous  cellular  tissue  is  formed,  by  which  the  viscus  becomes 
attached  and  agglutinated  to  adjoining  organs. 

Sometimes  there  is  but  one,  sometimes  there  are  several  of  these  cysts  ; 
in  rare  cases,  the  entire  liver  appears  converted  into  an  aggregation  of 
larger  or  smaller  sacs.  In  the  latter  instance,  two  or  more  are  often 
found  to  communicate  with  one  another ;  either  in  consequence  of  atrophy 
of  their  parietes  from  pressure,  of  rupture  from  inflammation,  or  from  a 
sudden  increase  in  their  contents. 

The  right  lobe  of  the  liver  is  the  ordinary  seat  of  the  acephalocysts ; 
the  largest  are  always  found  at  this  part. 

Acephalocysts  are  liable  to  inflammatory  attacks,  which  entirely  re- 
semble those  of  normal  serous  and  fibro-serous  membranes,  both  in  regard 
to  the  exudations  they  give  rise  to,  as  to  their  terminations  and  consecu- 
tive results.  They  may,  by  causing  suppuration  and  obliteration,  de- 
troy  the  vitality  of  the  acephalocysts,  and  thus  bring  about  a  cure. 

The  hepatic  acephalocyst  may  discharge  its  contents  in  various  direc- 
tions ;  the  portion  that  projects  above  the  surface  of  the  organ,  and  has 
lost  the  support  it  previously  received  from  the  surrounding  parenchyma, 
may  become  atrophied  and  thinned,  or  its  tissue  be  weakened  or  destroyed 
by  inflammation  and  suppuration,  and  thus  communicate  directly  with 
the  abdominal  cavity  ;  or  having  first  become  agglutinated  to  neighboring 


THE    LIVER.  119 

viscera,  it  may  perforate  the  latter  and  discharge  externally,  or  into 
other  cavities  and  canals.  The  contents  may  thus  make  their  way 

Into  the  right  pleura,  or  into  a  pulmonary  abscess,  and  be  removed  by 
the  bronchi : 

Into  the  intestinal  cavity,  and  especially  into  the  duodenum  and 
transverse  colon,  so  as  to  pass  off  by  vomiting  or  defecation : 

Into  the  gall-ducts,  i.  e.  into  a  large  branch  of  the  ductus  hepaticus, 
by  which  passage  they  may  ultimately  be  conveyed  into  the  intestine ; 
though  the  protrusion  of  the  acephalocyst  more  frequently  induces 
dangerous  obstruction  of  the  biliary  passages  : 

In  rare  cases,  into  a  neighboring  bloodvessel,  and  lastly  : 

Into  a  neighboring  circumscribed  abscess,  resulting  from  peritoneal 
inflammation. 

Occasionally  the  acephalocyst  opens  in  various  directions  at  once. 
After  the  discharge  of  its  contents,  obliteration  of  the  sac  and  cure, 
sometimes  follow. 

The  contents  of  the  sac  are  discharged  unaltered  or  changed,  accord- 
ing to  the  process  accompanying  its  perforation ;  the  products  of  inflam- 
mation in  the  matrix,  or  of  the  parietes  of  other  cavities  (e.  g.  the  pleura), 
the  bile,  the  intestinal  secretions,  &c.,  are  particularly  prone  to  induce  a 
maceration  and  complete  solution  of  the  acephalocyst. 

On  the  other  hand,  not  only  the  parietes  of  the  investing  sac  are  often 
found  saturated  with  bile,  but  the  bile  extravasated  from  large  gall-ducts 
is  frequently  mixed  with  its  contents,  and  its  parietes  are  incrusted  with 
inspissated  bile.  In  the  same  manner  we  may  now  and  then  discover 
blood  in  the  cyst,  which  has  been  discharged  from  neighboring  vessels. 

The  hepatic  parenchyma  is  forced  out  of  its  position  in  proportion  to 
the  size  and  number  of  the  cysts ;  if  otherwise  affected,  it  presents  the 
nutmeg  degeneration. 

Acephalocysts  in  the  liver  are  frequently  complicated  with  affections 
of  the  same  kind  in  other  organs,  as  the  lungs,  spleen,  and  kidneys ;  the 
disease  is  also  complicated  with  cancerous  affections  in  other  organs. 
Large  acephalocysts  of  the  liver  give  rise  to  ascites  or  peritonitis,  and 
may  thus  prove  fatal. 

In  reference  to  the  etiology  of  these  growths,  it  appears,  according  to 
some  observations,  that  mechanical  injury  of  the  liver  and  intermittent 
fevers  may  influence  their  development.  They  seem  not  to  occur  before 
puberty. 

(5.  Tuberculosis  of  the  liver. — Contrary  to  the  received  opinion,  we 
assert  that  the  liver  is  rarely  the  seat  of  tubercular  disease.  It  scarcely 
ever  occurs  in  this  organ  as  a  primary  affection,  but  is  not  unfrequently 
found  as  a  secondary  complication  of  advanced  primary  tuberculosis  in 
another  organ,  or  of  universal  tubercular  disease.  It  must,  therefore, 
almost  always  be  considered  as  the  expression  of  advanced  tubercular 
cachexia. 

Hepatic  tubercle  occurs  in  the  shape  of  semi-transparent,  grayish, 
crude,  miliary  granulations  ;  in  which  case  it  is  more  especially  the  pro- 
duct of  acute  tuberculosis ;  or  as  yellow,  cheesy,  adipose  deposits,  of  the 
size  of  a  hemp-seed,  or  pea,  or  more.  It  is  consequently  often  larger 


120  ABNORMITIES    OF 

than  pulmonary  tubercle ;  but,  on  the  other  hand,  with  the  exception  of 
very  rare  cases,  is  much  less  extensively  disseminated  than  the  latter. 

Hepatic  tubercle  is  not  limited  in  its  seat  to  a  particular  section  of 
the  viscus,  but  attacks  all  portions  indiscriminately,  and  the  more  so,  the 
acuter  its  course. 

The  tubercular  matter  is  deposited  in  the  parenchymatous  cellular 
tissue  of  the  organ,  and  especially  in  that  pertaining  to  the  biliary  capil- 
laries. It  very  frequently  surrounds  a  minute  gall-duct,  and  thus  pre- 
sents a  central  canal,  which  gives  rise  to  a  biliary  discoloration  of  the 
nucleus. 

When  the  liver  is  attacked  by  acute  tuberculosis,  its  appearance 
resembles  the  parenchyma  of  other  organs  similarly  affected ;  it  is  in  a 
peculiar  state  of  turgescence,  the  tissue  is  relaxed,  friable  and  pale,  and 
gorged  with  a  serous  or  sero-sanguineous  fluid.  All  this  will  be  the  more 
evident,  the  more  rapidly  the  tubercular  deposit  is  effected,  and  the  more 
the  universal  cachexia  is  developed. 

The  conditions  under  which  hepatic  tubercle  occurs,  render  it  apparent 
that  it  rarely  passes  into  the  stage  of  softening,  and  scarcely  ever  into 
that  of  cretification ;  the  constitutional  affection  generally  proves  fatal 
from  its  violence  and  diffusion,  before  the  tubercles  of  the  liver  have 
undergone  these  metamorphoses.  Still  we  do  occasionally  find  that, 
from  the  very  violence  of  the  constitutional  affection,  a  solution  of  hepatic 
tubercle  is  effected ;  and  then  it  is  probably  the  yellow  variety  which  is 
converted  into  a  primary  hepatic  vomica,  and  which  offers  no  peculiar 
characters  beyond  the  biliary  discoloration  of  its  contents. 

We  do  not,  however,  meet  with  a  condition  accompanying  tubercular 
suppuration  in  the  liver  which  may  be  considered  analogous  to  pulmonary 
phthisis. 

This  vomica  requires  to  be  the  more  carefully  distinguished  from 
morbid  dilatation  of  the  gall-ducts,  as  the  latter  not  only  occurs  frequently 
or  almost  invariably,  in  combination  with  hepatic  tubercle,  but  is  not 
unfrequently  coexistent  with  tubercular  disease  of  other  organs.  In  this 
case  small  cavities,  of  the  size  of  a  millet-seed  or  a  pea,  filled  with  viscid, 
muco-bilious,  dirty  green  matter,  with  flaccid  parietes,  are  found  scattered 
through  the  liver,  which  on  close  examination  are  found  not  to  be  tuber- 
cular, but  to  be  dilatations  of  capillary  gall-ducts.  The  hepatic  tubercles 
exist  at  the  same  time,  and  at  various  distances ;  a  tubercle  may  occa- 
sionally be  found  near  one  of  these  cavities,  but  it  is  not  characterized 
by  the  symptoms  of  secondary  deposit  accompanying  the  fusion  of  tuber- 
cular matter. 

The  conditions  of  their  origin,  and  their  connection  with  the  constitu- 
tional disease,  have  not  been  as  yet  ascertained ;  but  we  are  warranted 
by  numerous  observations  in  stating,  that  they  invariably  indicate  a  high 
degree  of  the  constitutional  affection ;  and  a  tendency  to  universal  tuber- 
cular deposition,  and  especially  in  the  abdominal  viscera. 

Hepatic  tubercle  may  be  complicated  with  tubercular  affections  of 
almost  all  organs,  as  might  be  assumed  from  its  originating  in  an  advanced 
stage  of  tubercular  dyscrasia ;  however,  the  abdominal  organs  are  found 
chiefly  implicated,  viz.  the  abdominal  lymphatic  glands,  the  spleen,  the 
peritoneum,  and  the  intestinal  canal. 


THE    LIVER.  121 

e.  Carcinoma  of  the  liver. — Carcinoma  of  the  liver  is  a  disease  of  much 
greater  importance  than  tubercular  deposition,  as  it  occurs  very  frequently 
and  is  often  a  primary  affection. 

Although  we  do  not  coincide  "with  Cruveilhier,  as  to  the  frequency  of 
its  occurrence,  it  still  must  be  considered  as  a  common  affection,  and  we 
would  give  its  numerical  relation  to  carcinoma  of  other  organs  as  one  to 
five.  The  greater  frequency  of  its  occurrence,  as  compared  with  tubercle 
of  the  liver,  and  considered  in  reference  to  the  frequency  of  both  affec- 
tions in  other  organs,  and  especially  in  the  lungs,  and  to  the  facts  con- 
nected with  the  formation  of  cysts  in  the  lungs  and  the  liver,  is  a  matter 
of  particular  interest. 

These  remarks  apply  to  carcinoma  of  the  liver  generally,  but  not  to 
its  different  varieties ;  of  these,  some  are  frequent,  some  occur  less  fre- 
quently, some  very  rarely. 

Four  varieties  of  carcinoma  are  found  in  the  liver,  which  we  will 
examine  in  succession. 

aa.  Areolar  cancer. — This  form  occurs  so  rarely,  that  it  is  never  de- 
scribed among  hepatic  affections.  One  case  of  very  extensive  areolar 
cancer  has  come  under  my  notice. 

,5,5.  Carcinoma  fasciculatum  sive  hyalinum  (Muller).  Although  not  as 
frequent  as  the  following,  it  undoubtedly  occurs  often.  It  is  generally  taken 
for  medullary  carcinoma,  and  the  mistake  is  accounted  for  by  the  fact 
that  the  two  often  coexist.  It  forms  masses  of  the  size  of  a  filbert  to 
that  of  a  man's  fist,  which  are  surrounded  by  an  investment  of  delicate 
cellular  tissue ;  though  the  surface  is  uneven  and  lobulated,  the  general 
outline  is  round ;  its  consistency  varies,  being  sometimes  but  slight,  at 
others  almost  cartilaginous ;  its  color  a  pale  yellowish-red,  and  generally 
of  almost  vitreous  transparency.  The  carcinomatous  masses  are  com- 
monly found  in  considerable  numbers,  and  like  medullary  cancer,  they 
cause  rounded  protuberances  of  the  viscus,  and  produce  an  increase  in 
its  weight  and  size. 

77.  Medullary  carcinoma. — This  is  the  most  common  form  of  hepatic 
cancer,  and  almost  all  investigations  that  have  hitherto  been  made  in 
reference  to  this  subject,  treat  of  this  variety  only.  It  occurs  either  in 
the  shape  of  detached  masses,  or  as  an  infiltration  of  the  hepatic 
parenchyma. 

aaa.  The  detached  masses  occur  as  tumors,  which  offer  many  peculiar 
features. 

Their  general  form  is  spherical,  though  their  surface  not  unfrequently 
is  slightly  racemose  or  lobulated.  Those  which  have  been  developed  in 
the  peripheral  portion  of  the  organ,  and  are  therefore  in  contact  with  the 
peritoneum,  present  a  flattened,  or  even  an  indented  surface,  and  the 
indentation  may  extend  to  the  very  nucleus  of  the  morbid  growth.  The 
peritoneal  lamina  in  the  indentation  is  opaque  and  thickened,  owing,  not 
as  is  commonly  thought,  to  cartilaginous  induration,  but  to  an  homolo- 
gous cancerous  degeneration  of  the  serous  and  subserous  tissue.  This 
condition  of  the  peritoneum  is  analogous  to  the  relation  the  common 
integument  bears  to  subjacent  cancerous  growths. 

In  size  the  medullary  cancer  varies  from  that  of  a  millet-  or  hemp-seed 
to  that  of  a  man's  fist,  a  child's  head,  and  more.  In  most  instances  mor- 


122  ABNORMITIES     OF    THE 

bid  growths  of  various  sizes  are  found  in  the  same  individual.  The  larger 
those  are  which  occupy  the  peripheral  portion  of  the  organ,  the  more 
prominent  will  be  the  protuberances  on  the  surface. 

The  number  of  these  adventitious  products  varies  equally ;  sometimes 
there  are  but  few,  or  even  only  a  solitary  one  is  found ;  at  others  they 
are  very  numerous.  The  greater  the  number  of  those  occupying  the 
peripheral  portion  of  the  organ,  the  more  numerous  will  be  the  protube- 
rances on  the  surface.  When  the  morbid  growths  are  numerous  and 
large,  two  or  more  often  coalesce. 

We  are  unable  to  discover  any  peculiarity  in  reference  to  their  posi- 
tion ;  they  commence  equally  in  the  peripheral  and  in  the  deeper-seated 
portions  of  the  intestine.  They  commonly  make  their  first  appearance 
in  the  right  lobe. 

As  regards  consistence,  we  find  two  varieties  which  have  also  been 
considered  as  differing  in  texture.  They  do  not,  however,  constitute 
essential  distinctions,  but  are  merely  different  degrees  of  development  of 
the  same  morbid  growth. 

One  is  of  the  consistency  of  bacon,  and  presents  on  section  a  smooth 
homogeneous,  shining  surface,  of  a  dull  white  color,  and  without  a  trace 
of  bloodvessels.  On  pressure,  a  small  quantity  of  a  thick  creamy  fluid 
exudes  from  the  meshes  of  a  dense  fibrous  structure.  These  growths  are 
not  detached  from  the  adjoining  hepatic  tissue  without  considerable  diffi- 
culty ;  and  a  distinct  cellular  investment  can  scarcely  be  demonstrated. 
The  growths  belonging  to  this  variety,  when  coexisting  with  the  second, 
are  always  the  smaller  of  the  two. 

The  second  presents  the  physical  characters  of  true  encephaloid  dis- 
ease ;  its  general  color  is  milk-white,  it  is  more  or  less  vascular,  and 
consequently  in  part  gray,  yellow,  brownish,  red,  or  even  dark  red  ;  it  is 
very  spongy,  and  on  pressure  yields  a  large  quantity  of  a  thin  milky 
fluid,  which  is  contained  in  the  meshes  of  a  friable,  fibrous  tissue.  The 
tumors  are  invested  by  a  delicate  cellulo-vascular  sheath,  and  are  easily 
detached  from  the  hepatic  parenchyma.  When  occurring  simultaneously 
with  the  first  variety,  they  generally  form  the  large  morbid  growths. 

The  latter  evidently  represent  an  advanced  stage  of  the  morbid  growth, 
as  appears  not  only  from  the  foregoing  remarks,  but  also  from  the  rela- 
tions of  the  primary  cell.  (Vide  vol.  i.) 

/W.  Infiltrated  medullary  cancer  is  analogous  to  the  other  infiltrations 
of  the  hepatic  tissue,  which  we  have  already  discussed.  It  always  con- 
tains obliterated  and  obsolete  bloodvessels  and  gall-ducts,  which  are  gra- 
dually absorbed.  The  infiltration  attacks  larger  or  smaller  segments  of 
the  viseus ;  it  does  not  present  distinct  boundaries,  but  insensibly  passes 
into  the  normal  parenchyma.  It  rarely  occurs  without  nodulated  cancer. 
The  carcinomatous  mass  presents  the  same  two  varieties  in  reference  to 
consistence  and  to  its  elementary  constitution.  We  find  a  transition 
from  the  diffused  to  the  circumscribed  form  in  the  fact,  that  the  nucleus 
of  the  latter  is  sometimes  infiltrated  hepatic  tissue,  which  becomes  en- 
dowed with  independent  growth,  and  merely  forces  the  parenchyma  out 
of  its  place. 

The  larger  and  the  more  numerous  the  carcinomatous  masses  are,  the 


BILIARY    PASSAGES.  123 

more  extensive  the  cancerous  infiltration,  the  more  does  the  viscus  in- 
crease in  size  and  weight.  The  extracancerous  tissue  presents  the  nutmeg 
and  adipose  degeneration. 

Medullary  cancer  is  here,  as  elsewhere,  the  seat  of  hemorrhages,  which 
are  proportioned  to  the  rapidity  of  its  growth  and  the  looseness  of  its  tex- 
ture. In  rare  cases  it  penetrates  through  the  peritoneal  investment  of 
the  liver,  its  development  then  proceeds  with  extreme  energy,  and  it  in- 
duces exhausting  hemorrhages.  In  other  cases  it  perforates  the  coats  of 
large  gall-ducts  within,  or  of  the  biliary  passages  external  to  the  liver, 
and  grows  into  their  cavities.  In  the  infiltrated  form  we  not  unfrequently 
find  extravasations  of  bile  to  a  greater  or  less  amount. 

Medullary  cancer  rarely  passes  into  suppuration,  as  it  generally  termi- 
nates fatally  by  inducing  universal  cachexia  and  exhaustion.  Its  fusion  is 
still  more  rarely  found  to  take  place  within  a  fibrous  sheath,  as  is  com- 
paratively oftener  the  case  in  the  spleen.  Occasionally  nature  seems  to 
attempt  an  arrest  of  the  morbid  growth,  by  a  conversion  into  fat  or 
adipocire. 

Hepatic  cancer  undoubtedly  very  often  occurs  as  the  first  of  a  succes- 
sive series  of  cancerous  deposits ;  yet,  in  the  dead  subject,  it  is  commonly 
found  combined  with  carcinoma  of  the  lymphatic  glands,  that  are  seated 
near  the  biliary  passages  and  in  the  lumbar  region,  with  cancer  of  the 
stomach,  of  the  intestine  (especially  of  the  rectum),  of  the  peritoneum, 
of  the  kidneys,  and  with  universal  cancerous  infection.  It  is  often 
developed  with  remarkable  rapidity  after  the  extirpation  of  cancerous 
growths,  and  is  then  generally  accompanied  by  cancer  in  the  lungs. 

777.  Medullary  carcinoma  not  unfrequently  occurs  in  the  liver  in  the 
shape  of  cancer  melanodes  (melanosis),  and  equally  as  an  infiltration,  or 
in  circumscribed  masses.  We  find  the  most  varied  combinations  of  its 
elementary  molecules  with  those  of  pure  medullary  cancer. 

A  common  result  of  hepatic  cancer  making  its  way  outwards,  is  inflam- 
mation of  the  peritoneum ;  the  carcinomatous  liver  is  consequently  often 
found  agglutinated  to  neighboring  parts  by  means  of  cellular  or  cellulo- 
fibrous  tissue,  which  may  in  its  turn  be  subjected  to  cancerous  degenera- 
tion. 

SECT.    II. — ABNORMITIES    OF   THE   BILIARY   PASSAGES. 

We  now  come  to  the  consideration  of  the  diseases  of  the  gall-bladder 
and  its  efferent  duct,  those  of  the  ductus  communis  choledochus,  of  the 
ductus  JiepaticuS)  and  of  the  branches  and  ultimate  distribution  of  the 
latter.  We  include  the  entire  apparatus  under  one  head,  though  we 
shall  devote  a  special  consideration  to  the  peculiar  characters  exhibited 
by  separate  sections. 

§  1.  Excess  and  Defect  of  Formation. — In  rare  cases  a  congenital 
absence  of  the  gall-bladder  has  been  noticed,  an  anomaly  which  must 
not,  however,  be  confounded  with  obliteration  of  the  gall-bladder  which 
is  frequently  consequent  upon  inflammation.  When  there  are  two 
livers,  the  gall-bladder  and  the  entire  apparatus  correspond  ;  but  we  also 
find,  without  any  further  anomaly,  a  twofold  instead  of  a  single  common 


124  ABNORMITIES    OF    THE 

duct ;  the  two  ducts  then  either  both  open  into  the  duodenum,  or  one 
communicates  with  the  duodenum,  and  the  other  with  the  stomach. 

§  2.  Irregularities  of  the  Biliary  Passages  with  reference  to  Calibre. 
— Independently  of  congenital  enlargement  or  diminution  of  these  parts, 
we  find  important  acquired  anomalies  in  the  shape  of  dilatation  or  con- 
traction. 

Dilatation  either  affects  the  entire  apparatus  from  the  duodenal  orifice 
to  the  capillary  gall-ducts  equally  or  almost  equally,  or  it  only  affects 
larger  or  smaller  portions,  whilst  the  remainder  retains  its  ordinary  size. 
The  gall-ducts  are  capable  of  extreme  distension. 

We  find  that  dilatation  of  the  passages  is  caused  by  habitual  accumu- 
lation of  inspissated  bile,  and  by  everything  that  impedes  the  progress 
and  the  discharge  of  the  secretion.  We  allude  to  compression  of  the 
biliary  passage  within  and  external  to  the  liver  by  morbid  products  or 
enlarged  lymphatic  glands,  to  diminution  of  their  calibre  by  tumefaction 
of  the  coats,  by  cicatrices  or  unusually  large  folds  or  valves  of  the 
mucous  membrane ;  to  obturation  by  biliary  calculi,  by  morbid  growths 
projecting  into  the  cavity  of  the  biliary  passages,  by  catarrhal  or  croupy 
secretions.  Some  of  these  obstacles  occur  mainly  in  one,  others  in 
another  portion  of  the  apparatus.  If  the  impediment  occupies  the 
ductus  choledochus,  the  dilatation  gradually  extends  over  the  entire  ap- 
paratus ;  but  it  must  be  observed  that  the  dilatation  of  the  gall-bladder 
does  not  in  general  correspond  with  the  dilatation  of  the  other  portions, 
as  its  efferent  duct  (ductus  cysticus),  4from  opening  into  the  common 
duct  at  an  acute  angle,  is  compressed  by  the  enlarged  ductus  chole- 
dochus. The  more  completely  the  calibre  is  obstructed,  the  more  com- 
plete is  the  capillary  distension ;  the  more  rapidly  it  ensues,  so  as  not 
unfrequently  to  induce  rupture. 

The  ductus  choledochus  is  either  found  compressed  by  disorganized, 
and  especially  by  cancerous,  lymphatic  glands,  or  by  the  pancreas,  or 
the  passage  is  narrowed  by  the  tumefied  mucous  membrane  or  by  the 
tumefied  valve,  or  it  is  closed  up  by  a  biliary  calculus  or  a  carcinomatous 
tumor  from  without.  Occasionally  it  is  so  enormously  dilated  as  to  ex- 
ceed the  diameter  of  the  small  intestine ;  the  slower  this  effect  is  pro- 
duced, the  more  marked  will  be  its  active  character ;  and  the  distension 
extends  upwards,  passing  by  the  gall-bladder,  as  above  observed,  to  the 
hepatic  duct  and  its  ramifications. 

The  channel  of  the  ductus  cysticus  is  found  impaired  by  unusual 
flexures,  or  large  and  numerous  mucous  folds,  consequent  upon  previous 
elongation  and  distension,  by  cicatrices  and  cancerous  degeneration  ;  it 
may  become  perfectly  obliterated  by  the  same  means,  or  by  biliary 
calculi,  which  are  impacted  in  the  neck,  and  more  particularly  in  a 
lateral  dilatation  of  the  gall-bladder.  Enormous  dilatations  of  the  latter 
result,  which  in  the  course  of  time  induce  an  entire  change  in  the  tissue 
and  the  functions  of  the  mucous  membrane  of  the  gall-bladder. 

After  this  occlusion  has  been  rendered  complete,  the  residuary  bile  in 
the  gall-bladder  is  absorbed ;  the  mucous  membrane  secretes  mucus  more 
copiously,  in  proportion  to  the  irritation  exerted  upon  it  by  the  stagnating 
mucus  left  after  the  removal  of  the  specific  contents  of  the  bladder. 
The  secretion  gradually  accumulating,  the  gall-bladder  extends,  and 


BILIARY    PASSAGES.  125 

its  mucous  membrane  becomes  converted  into  a  serous  membrane,  which 
secretes  a  serous,  albuminous  fluid,  resembling  synovia ;  this  is  at  first 
opaque,  and  subsequently  becomes  clear,  and  we  detect  in  it,  with  the 
assistance  of  the  microscope,  nothing  but  solitary  flocculi  of  pigmentary 
matter,  and  a  few  crystals  of  biliary  fat.  This  affection  of  the  gall- 
bladder is  termed  hydrops  cystidis  felleae,  and  the  bladder  resembles  the 
sound  of  fishes,  being  converted  into  a  tense  capsule, — a  condition 
similar  to  that  developed  under  analogous  circumstances  in  the  Fallopian 
tubes,  the  ureters,  the  pelves  and  calices  of  the  kidneys,  and  even  in  the 
vermiform  process. 

The  new  lining  membrane  of  the  gall-bladder  is  subject  to  all  the  dis- 
eases to  which  serous  membranes  and  their  cavities  are  liable  ;  inflamma- 
tions occur  very  frequently,  giving  rise  to  the  most  various  exudations, 
and  terminations  as  various.  Among  the  latter,  we  allude  especially  to 
shrivelling  of  the  gall-bladder,  accompanied  by  diminution  of  its  con- 
tents. These  become  inspissated,  so  as  to  form  an  adipose  chalky  pulp, 
or  chalky  concretion,  with  a  subsequent  ossification  of  the  parietes. 

The  dilatation  of  the  biliary  ducts  in  the  interior  of  the  liver  is  either 
uniform,  and  affects  the  entire  organ  or  certain  portions  only,  or  it 
occurs  as  a  partial  saccular  dilatation  of  one  or  more  of  those  ducts.  In 
the  former  case  the  cause  is  generally  to  be  found  in  an  obturation  of  the 
biliary  channels  within  or  external  to  the  liver,  by  means  of  concretions, 
cancerous  growths,  or  croupy  exudation  ;  and  the  dilatation  very  fre- 
quently extends  from  the  ductus  choledochus  to  the  biliary  passages 
within  the  liver.  In  well-marked  cases  the  entire  capillary  network  be- 
longing to  this  apparatus  is  dilated  and  gorged  with  bile ;  the  paren- 
chyma of  the  liver  may  be  saturated  with  bile,  and  present  a  dark  yellow 
or  green  color ;  the  viscus  is  turgid,  though  pulpy  and  friable,  resembling 
the  condition  of  yellow  atrophy ;  the  larger  ducts  contain  bile  in  a  dis- 
organized state,  and  not  unfrequently  blood  in  a  similar  condition. 

This  affection  invariably  proves  fatal  with  symptoms  of  biliary  infec- 
tion of  the  blood,  and  consequent  cerebral  disease,  which  is  often 
combined  with  exudation  on  the  arachnoid,  with  intense  icterus  and 
extreme  pain  in  the  liver.  The  capillary  ducts  are  occasionally  rup- 
tured, and  this  gives  rise  to  larger  or  smaller  accumulations  of  bile  in 
the  deep-seated  portions  of  the  organ  ;  or  the  rupture  may  occur  in  the 
peripheral  layers,  at  spots  where  patches  of  dilated  gall-ducts  form 
rounded,  fluctuating  projections  on  the  surface  of  the  organ ;  in  this  case 
the  hepatic  peritoneum  frequently  becomes  involved,  and  extravasation 
may  take  place  into  the  abdominal  cavity.  Finally,  the  bile  that 
transudes  through  the  coats  of  the  gall-ducts  may,  if  it  reaches  the  peri- 
toneum, induce  peritonitis,  which  in  its  turn  predisposes  to  rupture  of 
the  serous  covering  investing  the  approaching  biliary  abscess. 

The  second  or  saccular  form  of  dilatation  of  the  biliary  ducts  is 
generally  the  result  of  a  catarrhal  or  blennorrhoic  condition.  Capsules 
varying  in  size  from  a  pin's  head  to  a  hen's  egg,  with  a  loose  mucous 
lining  that  forms  valvular  folds,  are  found  scattered  through  the  liver, 
and  they  contain  a  liquid  consisting  of  blennorrhoic  or  purulent  mucus 
and  bile,  which  deposits  a  sediment  or  incrustations.  The  character  of 
the  investing  membranes  affords  a  sufficient  distinction  from  other  cavi- 


126  ABNORMITIES    OF    THE 

ties  containing  a  similar  fluid ;  but  the  afferent  and  efferent  canal  is  not 
easily  discoverable,  even  with  the  assistance  of  injections.  These  dilata- 
tions undoubtedly  originate  in  an  accumulation  of  catarrhal  secretion, 
and  are  generally  accompanied  by  a  dull  pain  in  the  liver. 

Contraction  of  the  biliary  passages  is  induced  by  the  above-mentioned 
circumstances,  and  may  advance  to  adhesion  and  obliteration,  as  is 
especially  the  case  in  the  gall-bladder. 

§  3.  Anomalies  in  the  Form  and  Disposition  of  the  Biliary  Pas- 
sages.— Among  these  we  reckon  the  various  congenital  malformations  of 
the  gall-bladder,  in  which  it  presents  an  intestinal,  cylindrical,  extended, 
twisted,  pyriform,  or  phial-shaped  appearance,  or  in  which  it  seems 
divided  longitudinally  or  transversely,  owing  to  a  rigid  condition  of  the 
internal  folds.  To  this  class  also  belongs  the  anomalous  insertion  of  the 
ductus  choledochus  into  the  duodenum  or  stomach.  The  acquired  mal- 
formations consist  in  contraction,  obliteration,  or  dilatation  of  the  gall- 
bladder ;  in  change  of  position  of  the  biliary  passages,  owing  to  pressure 
exerted  upon  them  by  enlarged  lymphatics,  morbid  growths,  &c. 

§  4.  Solutions  of  Continuity. — We  regard  as  peculiarly  interesting 
the  spontaneous  ruptures  occurring  in  the  biliary  passages  external  and 
internal  to  the  liver  as  a  consequence  of  excessive  dilatation,  which  is 
generally  preceded  or  accompanied  by  inflammatory  action.  "We  have 
also  to  cite  the  perforations  of  the  biliary  passages  external  to  the  liver, 
resulting  from  suppuration  of  their  cyats,  and  the  abnormal  passages 
subsequently  established  between  the  biliary  ducts  and  the  stomach  and 
intestinal  canal ;  as  well  as  certain  abscesses  produced  by  suppuration  of 
the  capillary  gall-ducts  within  the  liver,  of  which  we  shall  have  occasion 
to  speak  more  fully  in  the  sequel.  (See  Textural  Diseases  of  the  Biliary 
Passages.) 

§  5.  Textural  Diseases,  a.  Inflammation. — We  often  observe  catar- 
rhal inflammation  occurring  in  the  biliary  passages,  with  various  termi- 
nations and  results.  Like  catarrhs  of  other  mucous  membranes,  it  not 
unfrequently  is  a  primary  affection,  and  becomes  chronic,  or  it  as  often 
is  propagated  from  the  intestine  to  the  gall-ducts ;  but  it  often  evidently 
has  its  origin  in  the  irritation  caused  by  an  accumulation  or  an  altera- 
tion in  the  composition  of  the  bile,  and  especially  by  biliary  calculi.  At 
the  bedside  the  affection  is  undoubtedly  often  mistaken  for  irritation  and 
inflammation  of  the  hepatic  parenchyma. 

Owing  to  the  paralytic  state  induced  in  the  contractile  and  irritable 
layer  of  their  coats,  and  to  the  accumulation  of  bile,  the  gall-ducts  become 
distended,  their  mucous  membrane  relaxed  and  tumid,  and  the  muscular 
coat  hypertrophied  ;  within  the  liver  saccular  dilatations  are  formed  ;  the 
catarrhal  disease  induces  a  stagnation  of  bile,  which  gives  rise  to  calcu- 
lous  concretions,  and  occasionally  suppuration  and  perforation  of  the  gall- 
ducts  follow.  In  the  range  of  the  biliary  capillaries  it  most  probably 
causes,  in  the  manner  just  described,  the  formation  of  peculiar  accumula- 
tions (abscesses),  which  are  remarkable  for  the  blennorrhoic  pus  and  the 
bile  they  contain,  and  are  thus  distinguished  from  the  products  of  paren- 
chymatous  inflammation  of  the  liver. 


BILIARY    PASSAGES.  127 

Inflammation  originating  in  irritation,  caused  by  biliary  calculi,  de- 
serves a  special  consideration,  on  account  of  its  terminations  and  its  con- 
sequences ;  it  occurs  chiefly  in  the  gall-bladder.  Occasionally  and  par- 
ticularly when  brought  on  by  an  accumulation  of  bile  from  obturation  of 
the  neck  of  the  bladder  or  of  the  ductus  cysticus,  it  runs  a  very  rapid 
course,  attacking  the  submucous  tissue  of  the  gall-bladder,  and  terminat- 
ing in  rupture  and  effusion  of  its  contents  into  the  peritoneal  cavity.  At 
other  times  it  proceeds  more  slowly,  and  after  repeated  relapses,  induces 
suppuration  and  ulcerative  perforation  of  the  gall-bladder.  The  latter 
is  most  liable  to  occur  at  the  dependent  portion,  which  is  chiefly  exposed 
to  irritation,  viz.  the  fundus  of  the  bladder ;'  and  as  previous  peritoneal 
exudation  will  have  agglutinated  it  to  adjoining  viscera,  the  suppuration 
extends  to  them,  giving  rise  to  abscesses  in  the  liver  itself  above  the  gall- 
bladder, or  in  the  lesser  omenturn ;  or  establishing  fistulous  passages 
through  the  abdominal  parietes,  or  communications  between  the  gall- 
bladder and  the  pylorus,  the  duodenum  and  the  transverse  colon.  Lastly, 
in  favorable  cases,  the  coats  of  the  gall-bladder  may  be  converted  into  a 
fibrous,  callous  tissue  ;  its  contents  are  discharged  by  the  normal  or  by 
the  above-described  anomalous  passages,  and  the  organ  represents  a  thick- 
coated  hollow  capsule,  with  or  without  cicatrices  on  its  inner  surface, 
and  containing,  according  to  the  condition  of  the  mucous  membrane,  a 
mucous  or  serous  fluid,  and  not  unfrequently  one  or  more  calculi.  This 
is  the  so-called  obliteration  or  atrophy  of  the  gall-bladder.  The  calculous 
inflammations  of  the  biliary  passages  are  followed,  though  less  frequently, 
by  similar  results,  viz.  rupture,  suppuration,  gangrenous  perforation,  cal- 
lous induration,  and  obliteration. 

b.  Croupy  inflammation  is  of  very  rare  occurrence.     We  have  ob- 
served it  in  the  mucous  membrane  of  the  gall-ducts  in  the  liver,  accom- 
panying cholera-typhus  and  ileo-typhus.     It  gives  rise  to  tubular  exuda- 
tions, in  which  the  bile  forms  branched  concretions  which  block  up  the 
passages,  and  thus  cause  dilatation  of  the  capillary  gall-ducts. 

We  have  already  noticed  the  occurrence  of  the  secondary  and  gangre- 
nous typhous  process  on  the  mucous  membrane  of  the  gall-bladder. 

c.  (Edema  of  the  coats  of  the  gall-bladder. — Serous  infiltration  of  the 
coats   of  the  gall-bladder  occurs  in  general  dropsy,  and  especially  in 
ascites,  and  also  in  the  shape  of  subserous  infiltration  in  inflammation  of 
the  peritoneum. 

d.  Adipose  deposits  in  the  coats  of  the  gall-bladder. — An  excessive 
deposit  of  fat  under  the  peritoneal  investment  of  the  gall-bladder  only 
occurs  as  an  accompaniment  of  general  adipose  accumulation,  or  at  least 
of  accumulation  of  fat  in  the  abdomen.     Its  occurrence  is  of  some  inte- 
rest, inasmuch  as,  like  the  fatty  deposit  in  the  heart,  it  is  likely  to  in- 
duce fatty  degeneration  of  the  muscular  layer. 

§  6.  Adventitious  Products,  a.  Fibroid  tissue. — Under  this  head 
we  class  the  textural  alteration  occurring  in  atrophy  of  the  gall-bladder 
after  inflammation. 

b.  Anomalous  osseous  deposit — ossification,  as  elsewhere  in  mucous 
canals,  takes  place  only  as  a  consequence  of  previous  textural  alteration 
of  another  kind.  Thus  we  find  subserous  osseous  lamellae  formed  in  the 
parietes  of  the  gall-bladder,  after  it  has  been  converted  into  a  sero- 


128  ABNORMITIES    OF    THE 

fibrous  capsule,  in  hydrops  cystidis ;  or  the  fibroid  tissue  which  is  deve- 
loped  in  the  parietes  of  the  gall-bladder,  as  a  consequence  of  inflamma- 
tion and  partial  suppuration,  may  ossify. 

c.  Tubercular  deposit  in  the  biliary  passages  is  of  very  rare  occur- 
rence. 

d.  Carcinoma  of  the  biliary  passages  is  chiefly  met  with  as  a  compli- 
cation of  cancer  of  the  liver,  but  also  of  the  lumbar  lymphatic  glands, 
and  of  the  stomach.     It  occurs  either  as  an  idiopathic  nodulated  deposit 
in  the  submucous  tissue,  in  rare  cases  giving  rise  to  annular  stricture  and 
degeneration  of  the  entire  bladder  into  a  cancerous  capsule,  or  as  can- 
cerous infiltration  of  the  mucous  membrane ;  or,  as  is  more  commonly 
the  case,  the  biliary  passages  are  attacked  from  without,  cancerous  growths 
in  the  vicinity  perforate  the  parietes,  and  push  their  way  into  the  cavity. 
The  gall-bladder  is  most  frequently  attacked  by  hepatic  cancer ;  the 
ductus   choledochus   by  carcinoma  of  the  lymphatic  glands.     Obtura- 
tion of  the  passages  and  hemorrhage  are  common  consequences  of  the 
affection. 

§  7.  Anomalous  Contents  of  the  Biliary  Passages. — The  most  remark- 
able are  those  entirely  abnormal  contents  of  the  biliary  passages,  which 
are  either  the  product  of  textural  changes  and  morbid  processes  in  their 
coats,  or  which  after  being  generated  externally,  are  conveyed  into  the 
cavity  by  various  passages.  We  allude  to  the  sero-albuminous  fluid  of 
dropsy  of  the  bladder,  to  mucus,  to  pus  that  has  been  formed  in  the 
biliary  passages,  or  in  hepatic  abscessed,  to  blood  derived  from  cancer- 
ous growths,  to  acephalocysts  from  the  liver,  lumbrici  from  the  intes- 
tine, &c. 

The  bile  itself  presents  great  varieties  as  to  quantity,  but  more  still 
as  to  quality ;  in  the  majority  of  instances  the  anomaly  has  its  origin 
not  so  much  in  disease  of  the  liver,  as  in  morbid  conditions  of  other 
organs,  especially  of  the  intestine  and  of  the  portal  blood. 

As  regards  quantity,  the  bile  is  found  accumulated  to  a  large  amount 
in  the  biliary  passages  and  intestine,  or  it  is  remarkably  scanty.  It  is  to 
be  observed  that  in  the  latter  case  the  deficiency  is  sometimes  compen- 
sated by  the  saturated  condition  of  the  fluid. 

The  qualitative  anomalies  of  the  bile  are  more  numerous  and  impor- 
tant, and  affect  both  its  physical  and  its  chemical  constitution. 

The  color  of  the  bile  varies  extremely :  it  may  be  pale  yellow,  ochrey, 
orange-colored,  yellowish-brown,  blackish-brown,  black,  or  of  all  the 
different  shades  and  tints  of  green.  The  consistency  of  the  bile  gene- 
rally increases  in  a  ratio  with  the  increased  depth  of  color,  varying 
from  the  fluidity  of  water  to  the  density  of  tar  and  of  calculous  concre- 
tions. In  taste  it  varies  as  to  the  amount  of  bitterness,  but  it  may  also 
be  more  or  less,  or  entirely,  saccharine,  saline,  sour,  alkaline,  acrid,  or 
insipid. 

In  reference  to  its  chemical  constitution,  the  bile  presents,  as  might  be 
inferred  from  its  physical  qualities,  numerous  deviations  from  the  correct 
standard ;  the  chief  constituents  vary  in  their  relative  proportions,  or 
they  are  replaced  by  new  anomalous  substances. 

The  biliary  calculi  are  of  considerable  importance.     They  originate  in 


BILIARY    PASSAGES.  129 

a  morbid  constitution  of  the  bile,  which  may  be  abnormal  when  secreted, 
or  subsequently  become  so  from  stagnation  and  retention.  They  occur 
in  the  biliary  passages  external  to  and  within  the  liver,  but  more  espe- 
cially in  the  gall-bladder. 

Here  too  we  find  numerous  variations  with  regard  both  to  physical 
qualities  and  to  chemical  composition. 

They  vary  in  size  from  a  millet-seed  to  a  hen's  egg,  and  more.  We 
generally  find  the  largest  to  be  formed  by  several  materials  disposed  in 
layers,  with  a  preponderance  of  fatty  matter.  The  larger  they  are,  the 
less  numerous  will  they  be  ;  sometimes  several  hundreds  of  small  calculi 
are  discovered  in  the  gall-bladder. 

Their  form  and  surface  vary  much.  Single  calculi  are  commonly 
round,  oval,  or  cylindrical ;  when  very  large,  so  as  to  occupy  the  entire 
cavity  of  the  gall-bladder,  they  are  frequently  slightly  curved ;  if  several 
are  present  at  the  same  time,  they  mutually  prevent  their  enlargement, 
and  in  consequence  of  the  friction  and  pressure  they  exert  upon  one 
another,  they  assume  cubical,  tetrahedric,  prismatic,  or  irregularly  poly- 
hedric  shapes,  with  convex  or  concave  surfaces. 

The  calculi  found  in  the  ducts  are  generally  cylindrical,  occasionally 
branched,  or  entirely  amorphous.  Their  surface  may  be  smooth  and  unc- 
tuous to  the  touch,  or  rough,  racemose,  uneven,  of  a  mulberry  appearance, 
crystalline,  or  branched. 

The  texture  of  the  calculi  may  be  uniform  or  varied,  in  proportion  as 
they  consist  of  one  substance,  or  of  several  layers.  Many  show  no  dis- 
tinct arrangement ;  some  have  an  earthy  pulverulent  fracture,  or  a 
fibrous,  striated,  laminated,  micaceous  texture,  presenting  a  glassy,  silky, 
or  asbest-like  gloss  on  fracture,  as  is  particularly  observed  in  calculi 
consisting  of  cholesterine. 

Generally  speaking,  they  are  not  very  hard,  and  may,  when  first  re- 
moved from  the  body,  be  easily  compressed  between  the  fingers.  On 
drying,  they  crack  and  fall  to  pieces,  andj  at  last  become  pulverulent, 
which  is  particularly  the  case  with  those  concretions  which  consist  of  in- 
spissated bile  or  biliary  resin. 

In  color  they  vary  considerably ;  they  may  be  milk-white,  bluish, 
chalky,  light  or  dark-yellow,  brown,  black,  or  colorless,  or  transparent, 
with  a  slight  yellow  or  green  tinge.  Those  of  an  ochrey,  red,  green, 
and  blue  (bronzed)  color  are  unusual.  Sometimes  we  find  them  spotted, 
and  either  of  a  uniform  color  throughout,  or  varying  in  layers,  or  at 
least  containing  a  differently  colored  nucleus. 

Chemical  analysis  shows  the  biliary  calculi  to  consist  mainly  of  in- 
spissated bile,  biliary  resin,  coloring  and  fatty  matter,  and  the  calculus 
may  be  either  formed  of  one  of  these  substances  or  of  a  mixture  of 
several.  In  the  latter  instance  they  either  interpenetrate  one  another, 
or  are  disposed  in  distinct  layers,  which  are  distinguishable  by  their 
color  or  texture. 

Large  biliary  calculi  generally  contain  but  a  small  portion  of  inspis- 
sated bile ;  the  latter  often  forms  small  irregular  concretions  in  the 
gall-bladder,  or  larger  cylindrical  and  branched  concretions  in  the  gall- 
ducts,  or  it  serves  as  a  nucleus  to  the  various  calculi  of  the  gall-bladder. 
The  resin  and  pigmentary  matter  of  the  bile  enter  into  the  composition 

VOL.    II.  9 


130  ABNORMAL    CONDITIONS 

of  the  majority  of  gall-stones,  and  that  frequently  to  a  considerable 
extent. 

Cholesterine  almost  always  preponderates ;  it  frequently  occurs  in  a 
pure  state  as  a  white,  mother-of-pearl  like,  shining,  or  opaque  fatty  in- 
vestment, or  in  distinct  layers  of  a  striated  texture,  which  are  separated 
by  colored  resinous  layers  ;  it  may  also  exist  in  an  isolated  form,  depo- 
sited round  a  colored  nucleus,  and  give  rise  to  translucent  calculi  of  a 
striated  and  distinctly  crystalline  texture.  In  the  latter  case  we  gene- 
rally find  that  small  solitary  calculi,  in  the  former  very  large  calculi 
result. 

Picromel  commonly  occurs  but  in  minute  quantities,  in  biliary  calculi; 
the  various  salts  they  contain  form  but  a  small  proportion  compared  to 
the  amount  of  the  above-named  constituents.  Those  concretions  in  the 
gall-ducts  which  are  found  to  consist  of  carbonate  of  lime,  are  not  pro- 
ducts of  the  bile,  but  of  the  blennorrhoic  mucus  and  pus  of  the  gall- 
bladder. 

The  calculi  found  in  the  same  gall-bladder  generally  resemble  one  an- 
other in  composition,  shape,  and  size ;  although  we  meet  with  occasional 
exceptions  from  this  rule.  Thus  in  dropsy  of  the  gall-bladder,  we  often 
find,  beside  the  calculus  which  closes  up  the  cystic  duct,  and  which  is  of 
an  old  date,  and  of  complicated  structure,  a  second  crystalline  calculus, 
of  more  recent  formation,  which  consists  of  pure  cholesterine. 

The  calculi  are  either  unattached  or  sessile.  In  the  latter  case  they 
may  be  grasped  and  retained  by  a  portion  of  the  bladder,  or  be  aggluti- 
nated to  its  internal  surface  by  exudation,  or  they  may  be  included  in 
compartments,  formed  by  an  inspissated  albuminous  product  of  the  gall- 
bladder, o%by  organized  lymph  which  has  been  converted  into  fibrous 
tissue.  Small  calculi  are  also  occasionally  formed  within  small  saccular 
dilatations  of  the  biliary  mucous  membrane,  and  may  appear  to  lie  ex- 
ternal to  the  cavity  of  the  bladder. 

Biliary  calculi  frequently  cause  irritation,  inflammation,  and  subse- 
quent suppuration  of  the  coats  of  the  gall-bladder,  which  may  terminate 
in  various  ways.  Cicatrices  are  often  left,  which  more  or  less  diminish 
the  cavity.  They  may  induce  complete  occlusion  of  the  biliary  pas- 
sages, followed  by  dilatation  and  retention  of  bile.  We  must,  however, 
observe  that  sometimes,  owing  to  the  extreme  distension  which  the 
biliary  passages  are  capable  of,  calculi  of  the  size  of  a  hen's  egg  are 
enabled  to  pass. 

Biliary  calculi  are  of  common  occurrence.  We  have  observed  that 
their  formation  is  peculiarly  coincident  with  excessive  deposit  of  adipose 
tissue  and  with  carcinoma. 

The  entozoa  occurring  in  the  human  gall-bladder  are  the  endogenous 
acephalocyst  of  the  hepatic  parenchyma  and  the  distoma  hepaticum. 

SECTION  III. — ABNORMAL  CONDITIONS  OF  THE   SPLEEN. 

§  1.  Defect  and  Excess  of  Formation. — The  spleen  is  generally  absent 
in  acephalous  monsters,  together  with  other  organs  of  the  abdomen  and 
thorax.  Occasionally  it  is  found  wanting,  together  with  the  stomach  or 
the  fundus  of  the  stomach,  in  subjects  that  are  otherwise  well  developed, 


OF    THE     SPLEEN.  131 

or  it  exists  in  a  rudimentary  state,  whilst  the  stomach  is  in  a  normal 
condition.  The  explanation  of  these  phenomena  is  to  be  sought  in  the 
history  of  the  development  of  the  embryo. 

The  spleen  is  found  double  in  biventral  monstrosities.  The  multipli- 
cation of  the  spleen,  in  the  shape  of  lienes  succenturiati,  is  not  to  be 
viewed  as  an  increase,  but  as  a  subdivision  of  the  organ,  which  does  not 
affect  its  individuality.  We  not  unfrequently  find,  besides  the  main 
organ,  small  accessory  spleens  (lienes  succenturiati)  seated  in  the  omen- 
turn  and  ligamentum  gastrolienale.  They  vary  in  size  from  that  of  a 
millet-seed  to  that  of  a  walnut,  and  in  number  from  one  to  twenty. 
They  are  round,  present  the  same  structure  as  the  spleen,  and  are  mor- 
bidly affected  at  the  same  time,  and  in  a  similar  manner  as  the  latter. 
The  marginal  indentations  of  the  spleen,  or  the  complete  separation  of 
a  portion  of  the  organ  by  a  horizontal  fissure,  form  transitions  to  this 
abnormal  condition. 

§  2.  Deviations  of  Size. — Deviations  of  size  consist  either  in  an  abnor- 
mal increase  or  diminution  of  the  organ.  The  former  is  of  particular 
importance,  and  those  tumors  afford  a  special  interest,  which  depend 
upon  congestion  caused  not  by  mechanical  impediments,  but  by  the 
peculiar  relation  of  a  morbid  state  of  the  blood  to  the  spleen.  With  the 
rare  exceptions  of  those  cases  in  which,  like  analogous  states  of  the 
liver,  they  are  congenital,  these  conditions  are  acquired.  They  are 
either  acute  or  chronic  :  in  the  former  case  they  accompany  other  acute 
diseases,  either  during  their  entire  course,  or  only  during  single  stages ; 
in  the  latter,  the  tumefaction  results  from  dyscrasiae  or  cachectic  con- 
ditions, which  induce  congestion,  induration,  and  hypertrophy  of  the 
spleen.  These  terms,  however,  from  referring  mainly  to  external  ap- 
pearances, are  apt  to  cause  the  real  nature  of  the  disease  to  be  over- 
looked. 

It  is  unnecessary  to  enter  more  fully  into  the  consideration  of  these 
changes  affecting  the  splenic  parenchyma,  which  are  evidenced  by  tume- 
faction, as  it  will  be  more  appropriate  to  treat  the  subject  under  the 
head  of  Textural  Diseases.  We  merely  add  the  following  remarks  : 

a.  Acute  tumefaction  is  generally  accompanied  by  considerable  soften- 
ing of  the  splenic  parenchyma  ;  chronic  tumefaction  by  increase  in  the 
consistency  of  the  organ.     It  is  questionable  whether  the  hypertrophy 
affects  the  elementary  tissue  and  constitution  of  the  spleen :  this  is  a 
point  which  requires  to  be  elucidated  by  further  research ;  but  there  is 
no  doubt  of  the  fibrous  trabeculae  of  the  spleen  and  its  fibrous  capsule 
becoming  hypertrophied  in  old  chronic  tumors.     When  we  have  suc- 
ceeded in  reducing  an  acute  or  chronic  tumor,  or  even  a  mere  hyperaemic 
state  of  the  spleen,  we  often  find  the  sheath  of  the  spleen  thickened, 
opaque,  corrugated,  and  relaxed  after  death — a  fact  which  may  serve  as 
a  useful  indication. 

b.  The  size  attained  by  chronic  tumors  of  the  spleen  is  often  very 
considerable.     The  spleen  not  unfrequently  measures  sixteen  inches  in 
its  long,  seven  inches  in  its  short  diameter,  and  four  inches  in  thickness ; 
its  weight  may  amount  to  thirteen  pounds  and  a  quarter,  and,  according 
to  the  observations  of  others,  even  to  twenty  and  more  pounds. 


132  ABNORMAL    CONDITIONS 

Diminution  of  the  spleen  is  characterized  by  shrivelling  of  the  fibrous 
tissue,  which  prevents  the  vessels  from  being  injected ;  and  is  peculiar 
to  genuine  cholera  (cholera  algida),  or  it  occurs  as  atrophy,  in  conse- 
quence of  a  special  change  in  the  fluids  at  large.  Under  this  head  we 
must  class  numerous  obscure  cases  of  permanent  diminution  of  the  spleen 
in  individuals  who  in  no  way  resemble  each  other,  of  the  reduction  of 
the  spleen  observed  by  some  pathologists  as  resulting  from  the  use  of 
steel,  and  of  the  senile  involution  of  the  spleen. 

Atrophy  varies  in  degree ;  it  occasionally  advances  to  such  an  extent 
during  the  involution  of  the  organ,  as  to  reduce  it  to  the  size  of  a  hen's 
egg  or  walnut. 

The  spleen  in  these  cases  is  paler  than  usual,  its  consistency  is  in- 
creased or  diminished,  the  organ  may  assume  the  toughness  of  leather, 
or  become  soft,  friable,  and  pultaceous.  Senile  atrophy  may  be  charac- 
terized in  the  following  manner  :  the  spleen  is  considerably  reduced  in 
size,  and  flabby ;  its  sheath  is  opaque,  corrugated  and  thickened,  but  at 
the  same  time  softened  and  easily  ruptured ;  the  parenchyma  consists  of 
a  pulp  which  is  of  the  color  of  rust  or  the  lees  of  wine,  and  which  is  en- 
closed in  dense  and  equally  friable,  fibrous  tissue.  We  not  unfrequently 
find  the  sheath  of  the  spleen  indurated  and  cartilaginous,  or  ossified, 
and  at  the  same  time,  ossification  of  the  arterial  ramifications  and  free 
calcareous  concretions  (phlebolithes)  in  the  veins  of  the  organ. 

§  3.  Deviations  of  Form. — We  not  unfrequently  meet  with  a  tongue- 
or  platter-shaped,  almost  cylindrical,  globular,  or  angular  spleen ;  its 
edges  may  be  more  or  less  notched,  which  is  particularly  the  case  with 
the  anterior  margin ;  and  the  indentation  may  extend  so  far  as  to  cause 
a  transverse  division  of  the  organ.  These  furrows  are  not  to  be  con- 
founded with  the  contractions  that  are  occasionally  produced  by  inflam- 
mation and  metastasis,  and  which  very  much  resemble  the  former. 

§  4.  Deviations  of  Position. — The  congenital  anomalies  that  come 
under  this  head  consist  in  the  spleen  occupying  a  place  external  to  the 
abdominal  cavity,  when  the  latter  is  fissured,  in  its  being  placed  in 
large  umbilical  hernise,  and  in  the  left  thoracic  cavity  when  the  dia- 
phragm is  absent,  and  in  a  varying  position,  consequent  upon  an  anoma- 
lous congenital  elongation  of  the  peritoneal  attachments. 

Acquired  deviations  of  position  consist  in  a  descent  of  the  spleen, 
when  forced  down  by  enlargement  of  the  left  side  of  the  thorax,  or  in  its 
being  pushed  up  by  dropsical  and  ascitic  accumulations,  or  by  a  tympani- 
tic  state  of  the  intestine  ;  in  its  dislocation  by  various  turners,  or  in  its 
descent  from  increase  in  size  and  weight.  Enlarged  spleens  sink  ver- 
tically into  the  left  mesogastric  region,  or  raise  the  diaphragm,  or  they 
descend  to  the  ileum,  and  in  the  case  of  a  still  further  increase  of  size, 
slide  off  from  the  latter,  so  as  to  occupy  a  diagonal  position  in  the  hy- 
pogastrium,  and  extend  over  the  right  ileum.  There  is  no  doubt  that 
the  spleen  occasionally  presents  very  loose  attachments,  and  remains 
freely  movable,  even  after  it  has  been  reduced  from  a  hypertrophied 
state  to  its  normal  size,  in  consequence  of  the  previous  traction  exerted 
upon  its  ligaments. 


OF    THE    SPLEEN.  133 

§  5.  Solutions  of  Continuity. — Under  this  head  we  class  injuries  of 
the  spleen  inflicted  by  cutting  instruments,  rupture  consequent  upon 
blows  or  knocks  received  in  the  region  of  the  spleen,  contusions,  as  in 
being  run  over,  concussions,  as  in  a  fall,  and  spontaneous  ruptures. 
The  latter  are  of  peculiar  interest,  as  they  are  the  result  of  acute  and  vio- 
lent tumefaction  of  the  organ,  proceeding  to  a  most  intense  degree.  We 
are  able  to  confirm  the  fact  observed  by  other  authors,  of  the  occurrence 
of  spontaneous  rupture  in  typhus,  in  typhoid  cholera,  and  in  the  hot 
stage  of  ague,  and  the  consequent  fatal  termination  from  hemorrhage. 

§  6.  Diseases  of  Texture. — The  chief  diseases  that  appertain  to  this 
class,  the  hypercemire,  the  so-called  infarction  and  hypertrophy,  and  in- 
flammation of  the  spleen,  require,  in  order  to  be  duly  appreciated,  not 
only  anatomical  proof  of  the  existence  of  the  disease,  based  upon  a  clear 
notion  of  the  structure  of  the  organ,  but  more  especially  an  advance  in 
•our  knowledge  of  the  pathology  of  the  blood  and  the  serum.  Numerous 
diseases,  and  more  particularly  the  simplest  derangements,  as  many 
cases  of  hypenemia,  can  only  be  elucidated  by  attending  to  these  points. 
These  diseases  of  the  spleen  are  probably  but  rarely  idiopathic ;  they 
almost  always  arise  from  certain  anomalies  of  the  blood  and  the  serum, 
or  from  certain  dyscrasise,  which,  though  little  known,  and  as  little  un- 
derstood, bear  a  remarkable  and  positive  relation  to  the  spleen.  The 
spleen  may  in  fact  be  considered  as  the  most  sensitive  test  for  a  variety 
of  dyscrasic  states  of  the  fluids.  An  acquaintance  with  this  connection 
may  serve  to  lift  the  veil  which  still  conceals  the  true  function  of  this 
organ.  We  shall  now  resume  the  consideration  of  tumefaction  of  the 
spleen,  upon  the  basis  of  the  above  remarks,  and  enter  into  a  more 
minute  investigation  of  the  subject  than  we  could  adopt  in  the  previous 
general  outline.  The  main  points  relating  to  deviations  of  consistency  will 
at  the  same  time  be  adverted  to. 

1.  Bypercemia,  anaemia. — Hypersemia  of  the  spleen  arises  either  from 
a  mechanical  impediment  in  the  circulation  of  the  blood,  or  from  the  pe- 
culiar relation  alluded  to  as  existing  between  the  spleen  and  certain 
anomalous  conditions  in  the  fluids. 

The  first  variety  occurs  in  organic  diseases  of  the  heart  and  in  hepatic 
obstructions,  though  not,  especially  in  the  former,  to  the  extent,  nor  as 
frequently,  as  might  be  expected  from  obstacles  or  stasis  affecting  the 
entire  system  of  the  vena  cava  and  venae  portoe.  The  deranged  circu- 
lating fluid  appears  to  have  no  affinity  for  the  tissue  of  the  spleen,  and 
to  be  thus  in  part  carried  off,  and  in  part  mechanically  retained.  This 
latter  portion,  in  the  first  instance,  induces  a  hyperaemic  turgor  of  the 
organ,  and  gives  it  a  dark-red  color,  and  subsequently,  as  is  generally 
the  case  in  these  hypersemise,  induces  hypertrophy  of  the  fibrous  tissue 
and  of  the  pulpy  parenchyma  of  the  spleen.  The  organ  is  more  consis- 
tent, indurated,  and  dense. 

The  second  form  accompanies  various  dyscrasic  conditions  of  the 
fluids,  and  in  proportion  to  their  duration  induces  an  acute  or  chronic 
tumor  of  the  spleen,  which  differs  in  appearance,  and  in  its  primary  and 
secondary  constitution,  according  to  the  nature  of  the  cause. 

The  hypenemioe  affecting  the  peripheral  portion  of  the  organ  not  un- 


134  ABNORMAL    CONDITIONS 

frequently  degenerates  into  inflammation  of  the  peritoneal  investment  of 
the  spleen ;  the  resulting  exudations  are  converted  into  the  cellular, 
cellulo-fibrous,  or  cartilaginous  tissues  and  adhesions,  so  often  found  upon 
spleens  that  have  formerly  been  tumefied. 

Anaemia  of  the  spleen  occurs  in  connection  with  the  above-mentioned 
reductions  in  size. 

2.  Tumors  of  the  Spleen. — We  have  already  discussed  the  tumors  of 
the  spleen  arising  slowly  or  rapidly  from  hyperaemia,  and  from  the  con- 
gestion of  dyscrasic  blood,  as  far  as  regards  the  mere  increase  of  volume. 
We  have  now  to  examine  them  more  closely  in  other  points  of  view. 

These  tumors  are  observed  in  typhus,  and  in  many  typhoid  states,  as 
in  cholera  typhus,  in  pyaemia,  and  in  anomalous  exanthematic  processes, 
as  occurring  from  disorganization  of  the  blood  after  erysipelas,  scarlatina, 
miliaria,  or  rheumatism,  as  found  in  drunkards,  and  in  acute  tubercular 
affections ;  they  occur  as  a  result  of  suppressed  menstrual  or  hemor- 
rhoidal  discharge,  of  intermittent  fever,  of  rickets,  of  lues  and  mercurial 
cachexia,  and  of  many  dyscrasic  tubercular  affections. 

These  tumors  differ  in  character,  and  are  owing  partly  to  the  hyper- 
aemia, partly  to  the  deposition  of  an  anomalous  fibrous  product  in 
the  parenchyma  of  the  spleen.  We  find  the  greatest  difference  in 
the  consistence  of  the  tumors ;  but  the  chronic  indurated  tumors,  are 
undoubtedly  soft  at  first,  and  subsequently  attain  greater  hardness, 
according  as  the  deposit  is  more  or  less  coagulable.  The  same  remark 
applies  to  the  color  of  the  tumor,  which  at  first  is  undoubtedly  red,  but  sub- 
sequently becomes  paler  in  proportion  as  the  coloring  matter  is  absorbed, 
and  the  hyperaemia  is  forced  to  yield  to  the  compression  exerted  upon  it 
by  the  deposit.  We  find,  as  regards  other  qualities,  that  the  morbid 
product  offers  very  prominent  varieties,  which  we  will  examine  in  the 
analysis  of  the  chief  tumors  that  follows  ;  the  finer,  though  not  less  different 
characters  we  leave  to  another  department  of  science,  which,  though  not 
yet  cultivated,  promises  many  and  very  important  results. 

a.  Among  the  tumors  which  accompany  acute  diseases  of  the  blood, 
those  of  typhus  are  distinguished  by  their  rapid  and  extensive  increase, 
by  their  lax  tissue,  both  of  which  circumstances  sometimes  predispose 
to  rupture,  and  by  the  dark-red  color  of  the  parenchyma.  This  variety 
originates  in  stasis  affecting  the  vascular  system  of  the  fundus  ventriculi, 
and  in  the  deposition  of  a  very  lax,  pultaceous,  semi-fluid,  blackish-red, 
dirty  violet,  or  lighter-colored  purplish  mass,  varying  in  amount,  and  re- 
sembling the  pulpy  medullary  matter  found  in  the  typhous  mesenteric 
tland.  If  this  substance  is  deposited  rapidly  to  a  large  amount,  the 
brous  trabeculae  of  the  spleen  are  rendered  soft  and  friable  by  exten- 
sion ;  and  if  the  deposit  is  very  soft,  the  viscus  presents  fluctuation. 

The  tumors  occurring  in  the  other  acute  dyscrasiae  above  alluded  to, 
are  more  or  less  allied  to  this  one.  When  accompanying  universal 
acute  tuberculosis,  the  eliminated  mass,  partially  at  least,  at  once  as- 
sumes the  characters  of  tubercle.  The  spleen  may  increase  from  a  slight 
enlargement  to  three,  four,  five,  and  six  times  its  normal  size. 

Tumors  occurring  after  suppression  of  the  above-mentioned  hemor- 
rhages do  not  generally  become  a  subject  of  anatomical  research  until 
they  have  attained  a  very  considerable  size.  They  are  most  probably 


OF    THE    SPLEEN.  135 

the  result  of  repeated  typical  (typische)  hyperaemiae,  and  would  be  found 
at  their  commencement  to  be  of  slight  consistency,  and  of  a  red  color. 
A  coagulable  fibrinous  deposit,  however,  takes  place,  and  the  tumor, 
therefore,  in  proportion  to  the  amount  of  coagulation,  becomes  hard, 
elastic,  and  indurated,  the  parenchyma  is  reddish-brown,  of  the  color  of 
fresh  muscle,  and  presents  on  section  a  fleshy  (sarcomatous)  appearance ; 
by  degrees  the  coloring  matter  is  absorbed,  the  organ  then  presents  a 
pale  red,  yellowish,  or  reddish-white  appearance,  and  resembles  fibrine 
that  has  been  washed.  During  the  hyperaemiae  the  fibrous  trabeculse  also 
increase  in  quantity  and  toughness,  so  that  the  tumor  becomes  more  re- 
sistant ;  the  fibro-serous  capsule  is  also  rendered  more  opaque,  and  is 
thickened ;  it  is  invested  with  a  cellular  pseudo-membrane,  resulting  from 
peritoneal  inflammation,  and  is  thus  attached  to  the  abdominal  parietes. 
The  deposit  gradually  increases  to  such  an  extent  as  to  induce  a  compres- 
sion of  the  vascular  portion  of  the  spleen,  and  to  render  it  impermeable  to 
injections  ;  for  the  same  reason,  the  tumor  gradually  becomes  paler,  and  a 
vicarious  development  of  the  vessels  at  the  fundus  of  the  stomach  ensues. 

The  third  variety  of  splenic  tumors  bears  a  general  affinity  to  those 
accompanying  the  above-named  cachexiae,  but  the  deposit  that  occurs  in 
them  and  is  substituted  for  the  parenchyma  of  the  organ  much  resembles 
bacon  in  consistency  and  appearance ;  the  organ  on  section  offers  a  very 
smooth  surface,  a  dull,  lardaceous  (speckig,  baconny),  waxy  gloss,  and 
its  superficial  layer  appears  partially  transparent ;  the  spleen  is  hard,  but 
breaks  with  a  peculiar  fracture ;  it  presents  a  color  varying  from  dark 
purple  to  pale  red,  and  the  blood  contained  in  the  vessels  is  pale  and 
seroUvS  ;  this  variety  of  splenic  tumor  is  often  coincident  with  the  analo- 
gous lardaceous  infiltration  of  the  liver  (vide  p.  100) :  it  may,  however, 
occur  in  an  isolated  form,  or  complicated  with  a  similar  affection  of  the 
kidneys  (a  variety  of  Bright's  disease).  Like  the  other  varieties,  this 
tumor  may  attain  an  extreme  size,  and  dropsy,  and  especially  ascites, 
are  common  results. 

b.  We  have  lastly  to  advert  to  the  fact  that  many  cases  of  swelled 
spleen  depend  upon  the  formation  of  certain  corpuscles,  in  addition  to 
the  coexisting  hyperaemia.  These  small  bodies  are  quite  distinct  from 
the  Malpighian  corpuscles,  found  in  the  spleens  of  some  graminivora ; 
they  are  minute  grayish-red,  or  grayish-white,  opaque,  soft,  deliquescent, 
vesicular  substances,  of  the  size  of  a  millet-seed,  which  occupy  the  paren- 
chyma of  the  spleen.  They  accompany  a  morbid  development  of  the  ab- 
dominal lymphatics,  and  especially  of  the  follicular  apparatus  of  the 
intestinal  mucous  membrane,  with  turgescence  of  the  mesenteric  glands, 
occurring  in  those  affections  of  children  and  young  subjects,  which  we 
have  spoken  of  at  page  61 ;  they  are  also  found  in  typhous  affections  of 
these  organs,  and  of  the  spleen,  and  indicate  a  predominance  and  quali- 
tative derangement  of  the  lymphatic  system.  They  are  consequently 
also  found  complicated  with  acute  and  chronic  tumors  of  the  spleen, 
and  are  not  to  be  confounded  with  acute  tuberculosis  of  that  organ. 

The  consistency  of  the  spleen,  as  may  be  gathered  from  the  above  re- 
marks, depends  almost  entirely  upon  the  state  of  aggregation  of  the 
parenchyma,  or  of  the  morbid  product  which  has  replaced  the  latter. 
The  condition  of  the  fibrous  tissue  also  influences  it  to  a  certain  extent, 


136  ABNORMAL    CONDITIONS 

but  it  varies  much  even  within  the  limits  of  its  physiological  condition. 
The  two  extremes  constitute  softening  and  induration  of  the  spleen,  which 
we  have  already  examined  in  their  strict  sense. 

In  very  rare  cases,  the  black  softening  of  the  tissues  of  the  fundus 
ventriculi,  is  accompanied  by  a  similar  affection  of  the  splenic  tissue, 
which  is  converted  into  a  black,  carbonaceous,  tarry,  semi-fluid  mass, 
originating  in  the  vascular  system. 

3.  Inflammation  of  the  Spleen. — The  very  important  conclusions  to 
be  derived  from  pathological  anatomy  in  reference  to  inflammation  of 
this  organ,  and  with  regard  to  its  influence  upon  sanguification,  will  be 
self-evident. 

We  cannot  doubt  that  the  pulpy  substance  of  the  spleen  may  be  the 
original  seat  of  inflammatory  action  ;  the  fact  has  not,  however,  been  as 
yet  anatomically  demonstrated ;  in  the  same  manner  it  is  not  improbable, 
though  by  no  means  proved,  that  many  acute  and  chronic  tumors  of  the 
spleen  may  be  the  product  of  inflammation. 

The  variety  of  inflammation  for  which  pathological  anatomy  affords 
an  explanation  is,  to  name  it  from  its  seat,  phlebitis,  i.  e.,  an  inflamma- 
tion of  the  numerous  anastomosing  and  tortuous  venous  canals  of  the 
spleen.  In  fact,  we  have  only  to  apply  the  doctrines  promulgated  with 
regard  to  inflammation  of  a  vein  to  a  venous  ganglion,  in  order  to  obtain 
a  correct  picture  of  inflammation  of  the  spleen ;  that  which  elsewhere 
takes  place  in  a  simple  vascular  tube  is  here  found  in  a  complicated 
venous  apparatus. 

This  inflammation  of  the  spleen  occurs  as  a  primary  or  as  a  secondary 
affection.  Whilst  the  former  is  as  rare  as  spontaneous  primary  inflam- 
mation of  a  vein,  the  latter  is  as  frequent  as  secondary  phlebitis. 

Primary  inflammation  of  the  spleen,  if  not  early  combated,  or  unless 
ending  in  resolution,  gives  rise  to  an  exudation  of  laudable  pus  or  fibrine. 
In  either  case  the  circulating  fluid  may  become  infected,  and  coagulation 
be  produced  in  the  most  various  regions  of  the  vascular,  and  especially 
in  the  capillary  system.  This  is  an  explanation  of  so-called  metastases. 
However,  this  is  unusual  in  the  case  of  fibrinous  exudation,  as  the  in- 
flamed vessels  are  closed  by  the  coagula,  causing  obliteration  and  subse- 
quent conversion  of  the  inflamed  part  of  the  spleen  into  a  fibro- cellular 
callus,  which  may  even  ossify. 

In  the  case  of  purulent  exudation,  inflammation  of  the  spleen  passes 
into  suppuration,  and  abscesses  form.  In  a  favorable  case,  the  abscess 
may  be  circumscribed  by  adhesive  inflammation,  and,  being  enclosed  in 
a  sac  formed  by  obliterated  parenchyma,  which  has  been  converted  into 
fibrous  tissue,  may  be  borne  for  a  long  period];  a  partial  absorption  of  the 
pus  may  take  place,  and  the  remainder  becoming  inspissated  be  reduced 
to  a  calcareous  greasy  pulp,  or  even  to  a  hard  concretion.  The  more 
common  case  is  that  the  parietes  of  the  abscess  also  put  on  inflammatory 
action,  and  suppurate,  in  consequence  of  which  the  abscess  generally  en- 
larges very  rapidly,  with  symptoms  of  violent  and  universal  reaction  in 
the  shape  of  hectic  fever.  We  then  have  a  case  of  florid  (floride)  splenic 
phthisis. 

If  the  inflammation  extends  to  the  sheath  of  the  spleen,  inflammation 
of  the  splenic  and  neighboring  peritoneal  surface  ensues  ;  an  occurrence 
which  is  analogous  to  the  communication  of  disease  from  an  inflamed 


OF    THE    SPLEEN.  137 

vessel  to  the  tissues  in  its  vicinity :  the  inflammation  is  not,  however, 
apt  to  spread  far. 

The  splenic  abscess  not  unfrequently  discharges, 

Firstly,  Into  the  abdominal  cavity;  the  pus  is  then  often  enclosed  by 
the  product  of  circumscribed  peritonitis,  -which  causes  the  formation  of  a 
sac,  bounded  by  the  external  wall  of  the  abdomen  and  the  diaphragm, 
the  fundus  ventriculi,  the  colon,  and  its  mesentery ;  the  entire  spleen  is 
thus  occasionally  destroyed  by  suppuration. 

Secondly,  Into  the  left  thoracic  cavity,  after  suppurative  destruction 
of  the  diaphragm,  or, 

Thirdly,  Into  the  cavity  of  the  transverse  colon,  and  into  the  stomach. 

Secondary  inflammation  of  the  spleen  is  of  frequent  occurrence  in  all 
cases  in  which  the  blood  is  poisoned  by  the  absorption  of  an  inflamma- 
tory product,  or  has  become  affected  in  an  analogous  way  spontaneously, 
a  fact  which  indicates  the  delicate  reaction  of  the  spleen  to  a  morbid  con- 
dition of  the  blood.  We  then  see  the  formation  of  inflammatory  spots, 
which  are  in  every  way  remarkable.  They  are  well  defined;  they 
always  occupy  the  peripheral  portion  of  the  organ,  and  generally  pre- 
sent a  cuneiform  shape,  the  base  being  at  the  surface,  the  apex  being 
directed  towards  the  interior ;  there  are  often  two,  three,  four,  and  more 
of  these  foci  present  at  the  same  time  ;  they  vary  in  size  from  that  of  a 
pea,  to  that  of  a  hen's  egg,  and  in  rare  cases  involve  an  entire  third  of 
the  viscus. 

The  substance  of  the  spleen  appears  considerably  darker  at  these  spots, 
from  the  commencement,  and  also  denser  and  more  resistant ;  it  subse- 
quently assumes  a  reddish-brown  color,  and  its  density  also  increases,  so 
that  the  affection'  may  be  at  once  identified,  even  externally ;  its  limits 
are  now  well  defined,  and  reactive  inflammation  is  set  up  in  the  adjoining 
tissue.  The  process  may  terminate  in  various  ways :  in  favorable  cases, 
especially  when  a  benignant  fibrinous  exudation  has  been  absorbed  into 
the  blood,  as  frequently  occurs  in  inflammation  of  the  internal  mem- 
brane of  the  bloodvessels,  and  particularly  of  the  endocardium,  the  dis- 
eased tissue  is  converted  into  a  cellulo-fibrous  callus,  which  contracts  and 
causes  a  cicatrix  at  the  surface,  by  drawing  the  sheath  of  the  spleen  in- 
wards. The  more  common  case  is  that  pus  or  ichorous  matter  is  absorbed, 
and  that  the  inflamed  portion  is  converted  into  a  puriform,  creamy  mass, 
or  into  a  sanious,  greenish,  greenish-brown,  or  chocolate-colored  pulp ; 
in  the  latter  instance,  the  conversion  is  often  effected  with  very  violent 
symptoms,  without  previous  induction  of  the  paleness  above  described. 

The  entire  process  is  a  detailed  repetition  of  that  occurring  in  secondary 
phlebitis,  and  is  nothing  more  than  the  metamorphosis  of  an  infected 
coagulum  within  the  channels  of  a  vascular  ganglion. 

When  the  disease  affects  the  peripheral  portions  of  the  organ,  peri- 
tonitis frequently  supervenes,  and  an  eschar  having  formed  in  the 
sero-fibrous  sheath,  a  discharge  into  the  abdominal  cavity  is  not  rarely 
effected. 

This  secondary  inflammation  of  the  spleen  is  a  very  frequent  compli- 
cation of  inflammation  of  the  internal  vascular  coat,  and  particularly  of 
endocarditis.  Of  all  organs  that  are  affected  in  a  similar  manner,  by  the 
absorption  of  a  product  of  inflammation  into  the  blood,  the  spleen  is  the 


138  ABNORMAL    CONDITIONS    OF    THE    SPLEEN. 

most  liable  to  be  attacked.  When  occurring  as  a  result  of  spontaneous 
disorganization  of  the  blood,  it  is  particularly  important  in  complication 
with  croup,  as  also  with  exudative  processes  on  mucous  and  serous  mem- 
branes, particularly  with  pneumonia,  and,  lastly,  with  the  analogous 
process  of  tubercular  disease. 

4.  Grangrene  of  the  Spleen. — Gangrene  is  as  rare  an  occurrence  in 
the  spleen  as  in  the  liver ;  we  have  had  an  opportunity  of  observing  it 
once  in  a  chronic  tumor  of  the  spleen,  affecting  the  organ  to  a  conside- 
rable extent. 

5.  Adventitious  growths,     a.  Anomalous,  fibrous,  and  fibro-cartila- 
ginous  tissue. — This  tissue  occurs — 

a.  Very  often  upon  the  surface  of  the  organ  underneath  its  peritoneal 
sheath,  in  the  shape  of  smooth  and  level,  or  tuberculated  plates,  of  vary- 
ing thickness  and  size.     It  occurs  in  this  shape  at  advanced  periods  of 
life,  as  a  result  of  the  congestion  to  which  the  parenchyma  and  the  in- 
vestment of  the  organ  have  been  exposed.     It  is  not  very  unusual  to  find 
these  laminse  of  such  an  extent  as  to  invest  the  entire  convexity  of  the 
spleen,  and  to  present  a  thickness  of  several  (two,  three,  and  five)  lines. 

fi.  It  occurs  very  rarely  in  the  shape  of  fibroid  tumors  of  the  paren- 
chyma of  the  spleen. 

b.  Anomalous  osseous  groivths. — We  find  them  occurring — 

«.  As  ossification  of  the  fibroid  laminae  just  described,  of  the  same 
extent  and  thickness  as  the  latter ;  they  are  rarely  found  except  in  very 
old  people ; 

/9.  As  cretified  fibrine  in  the  cellulo-frbrous  callus,  subsequent  to  pri- 
mary and  secondary  inflammation  of  the  spleen  ; 

Y.  As  round  unattached  concretions,  or  phlebolithes,  in  the  venous 
channels  of  the  spleen. 

c.  Formation  of  cysts. — Encysted  tumors  of  the  spleen  are  very  re- 
markable, and  as  unusual  as  cancer,  a  fact  which  is  interesting  on  account 
of  the  contrast  with  the  frequency  of  tubercle.     The  acephalocyst  is  either 
found  in  the  spleen  alone,  or  concurrently  with  one  in  the  liver ;  it  rarely 
attains  the  size  it  reaches  in  the  latter  organ,  but  is  otherwise  not  dis- 
tinguished by  any  peculiarity.     Cysts  with  other  contents  are  still  less 
frequent. 

d.  Tubercle. — Tubercular  disease  affects  the  spleen  only  less  frequently 
than  the  lungs  and  the  lymphatic  glands.     It  always  characterizes  an 
advanced  stage  of  tuberculosis,  which  had  previously  only  appeared  as 
chronic  disease  in  some  other  organ,  as  the  lungs,  the  brain,  or  the  lym- 
phatic glands,  or  had  merely  existed  in  a  latent  form,  and  is  now  con- 
verted into  acute  general  tuberculosis.     Splenic  tubercle  is  consequently 
always  complicated  with  tubercle  in  the  most  various  organs,  and  very 
frequently  with  universal  tubercular  deposit. 

Tubercle  of  the  spleen,  when  acute,  commonly  appears  in  the  shape  of 
numerous  densely-sown  granulations  of  the  size  of  a  pin's  head  or  millet- 
seed,  resembling  gray  transparent  vesicles,  or  of  an  opaque  white  color ; 
or  as  yellow  cheesy  masses,  varying  in  size  from  a  millet-seed  to  a  pea. 
When  chronic,  it  presents  the  shape  of  crude,  originally  gray,  granula- 
tions of  the  size  of  a  millet-  or  hemp-seed,  which  subsequently  are  con- 
verted into  a  cheesy  substance. 


ABNORMITIES    OF    THE    PANCREAS,    ETC.  139 

The  parenchyma  of  the  spleen  is  the  seat  of  tubercle  ;  we  not  unfre- 
quently  find  a  small  central  cavity  within  the  tubercle,  and  the  latter  is 
occasionally  surrounded  by  a  cyst  or  capsule  of  fibro-lardaceous  texture, 
a  fact  which  demands  special  investigations  for  its  elucidation. 

For  the  same  reasons  that  apply  to  hepatic  tubercle,  tubercle  of  the 
spleen  scarcely  ever  passes  beyond  the  stage  of  commencing  rarnollisse- 
ment. 

The  spleen  appears  swollen  in  proportion  to  the  quantity,  and  also  to 
the  size  of  the  tubercles :  in  acute  tuberculosis  its  turgescence  and  the 
relaxation  of  its  parenchyma  strongly  resemble  the  typhous  condition. 

e.  Cancer. — Cancer  occurs  very  rarely ;  we  have  as  yet  only  met  with 
the  medullary  variety  in  combination  with  cancer  of  other  organs,  espe- 
cially of  the  liver  and  the  lumbar  glands.  The  structure  of  the  spleen 
appears  to  afford  a  satisfactory  explanation  of  the  fact,  that  cancer  oc- 
curring in  it  is  frequently  invested  by  a  fibrous  sheath,  within  which  it 
passes  into  a  state  of  ichorous  solution.  The  sheath  is  formed  by  the 
displaced  fibrous  tissue  of  the  spleen,  which,  in  the  case  of  the  adventi- 
tious growth  attaining  a  considerable  size,  is  strengthened  by  the  fibrous 
investment  of  the  spleen. 

SECT.    IV. — ABNORMITIES   OF   THE   PANCREAS,   AND   THE   OTHER 
SALIVARY   GLANDS. 

We  shall  first  examine  the  abnormities  affecting  the  parenchyma  of 
the  above-named  glands,  and  then  proceed  to  examine  those  of  their 
efferent  ducts,  and  of  their  contents.  We  may  observe,  generally,  that 
these  organs  are  not  very  liable  to  become  diseased. 

§  1.  Abnormities  of  the  Pancreas  and  the  Salivary  Glands. — 1.  De- 
fect and  excess  of  formation. — Absence  of  the  pancreas  and  the  salivary 
glands  is  only  observed  in  very  imperfect  monstrosities ;  salivary  glands 
sometimes  present  an  arrest  at  a  very  low  stage  of  development,  inas- 
much as  they  may  be  blended  with  one  another  and  with  the  thymus  and 
thyroid  glands,  so  as  to  form  one  mass.  Excess  of  development  occurs 
very  rarely  in  the  shape  of  a  double  pancreas,  or  of  an  extravagant  de- 
velopment of  accessory  appendages. 

2.  Deviation  in  size. — Enlargement  of  the  above-named  glands,  in 
consequence  of  hypertrophy,  is  altogether  unusual;  but  when  it  does 
occur  it  affects  not  so  much  the  acini  themselves,  as  the  interstitial  cellular 
tissue.     The  gland  therefore  almost  invariably  becomes  more  compact 
and  drier,  and  then  presents  simple  non-malignant  induration. 

A  diminution  of  the  pancreas  is  the  result  of  atrophy.  Occasionally, 
and  particularly  at  an  advanced  age,  this  takes  place  spontaneously,  or 
it  may  be  induced,  secondarily,  by  other  anomalies,  such  as  chronic  in- 
flammation and  adipose  infiltration,  or  the  deposition  of  calcareous  matter 
in  the  efferent  ducts.  The  atrophic  state  is  accompanied  by  variations 
of  consistency,  the  organ  sometimes  presenting  coriaceous  tenacity,  at 
others  a  lax  and  pultaceous  condition. 

3.  Deviations  of  consistency. — We  meet  with  the  most  various  degrees 
of  consistency  in  the  pancreas.     The  two  extremes  only  come  within  the 


140  ABNORMITIES    OF 

range  of  pathology ;  they  are  on  the  one  hand  extreme  cartilaginous  dry- 
ness  of  the  tissue,  and  induration  which  is  generally  coupled  with  en- 
largement ;  on  the  other  extreme  softening,  relaxation,  and  succulence  of 
the  tissue. 

4.  Diseases  of  the  tissues,  a.  Inflammation. — Inflammation  of  the 
salivary  glands  is  either  acute  or  chronic,  and  it  is  either  primary  or 
secondary  ;  in  the  latter  case  it  is  metastatic.  Inflammation  of  the  pan- 
creas, at  all  events  in  the  acute  form,  is  extremely  rare  :•  this  is  not  the 
case  with  the  other  salivary  glands,  especially  with  the  parotis ;  here  the 
inflammation  is  very  pften  primary,  and  still  more  frequently  metastatic. 

The  acute  form  is  characterized  in  the  following  manner :  in  the  first 
instance  there  is  tumefaction  of  the  gland,  reddening,  congestion,  relaxa- 
tion, and  succulence,  i.  e.  infiltration  of  the  interstitial  cellular  tissue ; 
in  the  progress  and  in  the  higher  stage  of  the  disease,  a  sarcomatous 
condensation  of  the  cellular  tissue  follows  as  a  consequence  of  plastic 
exudation  into  its  areolae  ;  the  congestion  and  reddening  attack  the  acini, 
which  appear  to  be  fused  with  the  former,  and  the  entire  gland  is  enlarged 
and  indurated.  Unless  the  inflammation  pass  into  resolution,  small 
punctiform  abscesses  result,  which  enlarge,  become  more  numerous  and 
coalesce ;  the  gland,  and  particularly  the  cellular  tissue,  is  now  found 
uniformly  infiltrated  with  yellow  pus,  which  exudes  from  it  as  from  a 
sponge,  whilst  the  acini  appear  as  small,  red,  lax,  friable  corpuscles, 
which  fuse  at  a  later  period ;  or  suppuration  is  established  at  distinct 
spots  so  as  to  form  an  abscess,  which  may  discharge  itself  in  various  di- 
rections, subsequent  to  the  destruction  tff  the  adjacent  tissues. 

Chronic  inflammation  induces  condensation,  induration  of  the  cellular 
tissue,  obliteration  of  the  acini,  and  either  permanent  enlargement  or 
subsequent  atrophy  of  the  gland. 

The  metastatic  forms  of  inflammation  not  unfrequently  pass  rapidly 
from  the  stage  of  hypersemia  with  livid  redness,  into  sanious  ulceration, 
with  sudden  disappearance  of  the  turgor. 

b.  Adventitious  growths. — The  salivary  glands  are  not  very  subject  to 
the  formation  of  morbid  growths  ;  tubercle  is  never  discovered  in  them, 
and  carcinoma  rarely  attacks  them  primarily.  We  find  the  pancreas 
liable  to — 

a.  Excessive  accumulation  of  fat,  which  may  terminate  in  a  conversion 
of  the  entire  organ  into  one  mass  of  fat.  This  affection  rarely  occurs 
without  a  coincident  accumulation  of  fat  in  the  abdomen.  The  disease 
proceeds  from  without  inwards,  and  in  very  obese  persons  a  direct  com- 
munication may  be  traced  between  the  surrounding  fat  and  the  pancreas ; 
the  cellular  tissue  gradually  absorbing  the  lax  greasy  fat,  the  acini,  which 
are  of  a  dirty  yellow  color,  being  reduced  and  gradually  disappearing. 
When  the  disease  has  attained  its  extreme  limits,  a  mere  pultaceous  strip 
of  fat  retaining  the  general  outlines  of  the  gland  is  found  in  its  place ;  only 
scattered  remains  of  the  acini  are  discoverable,  and  in  the  delicate  and 
thinned  duct  there  is  a  whey-like  fatty  fluid.  The  disease  occurs  fre- 
quently in  drunkards,  associated  with  fatty  liver  and  the  formation  of 
biliary  calculi. 

ft.  Cysts. — Serous  cysts  are  occasionally  formed  in  the  pancreas,  as 


THE    PANCREAS,    ETC.  141 

well  as  in  other  salivary  glands.  They  are  to  be  carefully  distinguished 
from  dilatations  of  the  ducts  and  their  terminations,  which  put  on  a 
similar  appearance. 

.  Y'  Fibrous  tissue,  cartilaginous  and  osseous  growths.     Tumors  of  this 
description  occur  but  very  rarely  in  the  parotid. 

d.  Carcinoma. — Carcinomatous  disease  occurs,  in  the  pancreas  and  sali- 
vary glands,  and  especially  in  the  parotid,  in  the  shape  of  scirrhus  and 
medullary  cancer.  In  the  parotid  it  sometimes  appears  as  a  primary 
disease ;  in  the  pancreas  we  have  only  found  it,  and  even  then  exclusively 
at  its  duodenal  end,  as  a  complication  of  extensive  carcinoma  of  numerous 
other  organs.  The  secondary  affection  of  the  salivary  glands  by  an  ex- 
tension of  the  disease  from  adjoining  organs,  and  in  the  case  of  the  pan- 
creas especially,  by  an  extension  from  the  scirrhous  pylorus,  is  very 
common.  Cancer  appears  in  the  shape  of  infiltration  of  the  interstitial 
cellular  tissue  of  the  gland  or  of  nodes.  Dr.  Berg  has,  during  his  resi- 
dence in  Vienna,  discovered  carcinomatous  induration  of  the  entire  pan- 
creas in  a  new-born  child. 

§  2.  Abnormities  of  the  different  Ducts  and  of  their  Contents. — Next 
to  salivary  fistula  subsequent  upon  injuries  and  ulcerative  destruction  of 
the  tissues,  which  occurs  chiefly  at  the  ductus  stenonianus,  but  which  we 
have  also  seen  in  the  shape  of  pancreatic  fistula  (see  p.  39)  discharging 
by  a  perforating  ulcer  of  the  stomach,  we  find  dilatation  of  the  excretory 
ducts  and  of  the  ductuli  salivales  to  be  the  chief  and  most  frequent  affec- 
tion that  has  to  be  noticed  under  this  head. 

Dilatation  depends  mainly  upon  retention  and  accumulation  of  the  se- 
cretion, and  may  either  affect  the  entire  duct  or  one  portion  uniformly,  or 
small  detached  points,  so  as  to  form  saccular  or  varicose  dilatations ;  in 
the  latter  case,  again,  the  duct  may  present  single  fusiform  or  vesicular 
dilatations  at  intervals,  or  numerous  closely-set  expansions,  which  are 
partially  separated  from  one  another  by  valvular  folds  formed  by  the 
coats  of  the  duct.  The  coats  may  be  either  considerably  thickened  or 
considerably  attenuated. 

The  cause  is  generally  to  be  found  in  some  mechanical  impediment,  such 
as  compression  and  complete  obliteration  of  the  duct  external  or  internal 
to  the  gland  by  morbid  growths  of  various  descriptions.  In  the  pan- 
creatic duct  it  may  be  induced  by  gall-stones  occupying  the  orifice  of  the 
ductus  choledochus,  by  a  sudden  curve  or  angle  of  the  duct  brought  on 
by  cancerous  induration  and  shrivelling  of  the  normal  tissue,  with  change 
of  position,  such  as  we  often  observe  in  the  pancreatic  duct  near  the  head 
of  the  pancreas.  It  may  be  induced  by  tumefaction  of  the  internal  mem- 
brane, by  a  mucous  plug,  and  especially  by  calcareous  concretions  (sali- 
vary calculi).  In  rare  cases  the  dilatation  of  the  pancreatic  duct  is,  like 
that  of  the  bronchi,  brought  on  by  induration  and  atrophy  of  the  gland. 
In  morbid  softening  of  the  gland,  and  especially  in  the  adipose  meta- 
morphosis, the  duct  is  deprived  of  its  contractility,  and  dilatation  with  a 
marked  attenuation  and  relaxation  of  its  parietes  ensue  ;  lastly,  dilata- 
tions of  the  duct  may  take  place  without  any  mechanical  obstruction,  in 
consequence  of  scirrhoid  disease  of  its  duodenal  end ;  the  duct  in  this 
case  fuses  with  the  scirrhous  portion  of  the  gland  ;  it  is  thus  fixed,  the 


142        ABNORMITIES  OF  THE  PANCREAS,  ETC. 

scirrhus  involves  its  tissue,  whereby  its  vital  contractility  becomes  im- 
paired, and  the  secretion  is  allowed  to  stagnate  in  its  cavity. 

The  dilatations  of  the  pancreatic  duct  enlarge  to  the  size  of  a  goose's 
or  swan's  quill ;  the  saccular  expansions  may  reach  the  size  of  a  hazelnut 
or  pigeon's  egg.  -In  Wharton's  duct  the  dilatation  occurs  in  the  shape 
of  a  fluctuating  tumor,  and  is  known  as  ranula.  Dilatation  of  the  ductuli 
and  their  terminations  sometimes  puts  on  the  shape  of  serous  cysts. 

The  contents  of  the  salivary  ducts,  i.  e.  the  saliva  of  the  mouth  and 
stomach,  occasionally  offer  rather  remarkable  anomalies  in  reference  to 
quantity,  color,  consistency,  and  probably,  as  indicated  by  the  taste,  and 
especially  by  its  acid  or  alkaline  reaction,  in  reference  to  chemical  con- 
stitution. Not  unfrequently  calculous  concretions,  the  so-called  salivary 
calculi,  are  generated  in  the  saliva,  and  this  is  more  especially  the  case 
in  the  ducts  of  the  sublingual  gland  and  the  pancreas.  They  are  white, 
friable,  and  either  round,  oblong,  cylindrical,  or  obovoid ;  in  size  varying 
from  that  of  a  millet-seed  or  a  pea,  to  even  that  of  a  hazelnut ;  they  are 
either  solitary,  or  if  small,  frequently  very  numerous  (twenty  and  more) ; 
and  they  are  composed  of  phosphate  and  carbonate  of  lime,  held  together 
by  animal  matter.  These  calculi  give  rise  to  obturation  of  the  ducts,  and 
consequent  accumulation  of  the  secretion  and  dilatation. 

At  times,  blood,  pus,  cancerous  sanies,  is  found  in  the  salivary  ducts ; 
bile  is  not  unfrequently  discovered  in  the  pancreatic  duct ;  in  one  case  of 
migration  of  lumbrici  into  the  biliary  vessels,  two  were  found  to  have 
crept  into  the  latter. 


PART  II. 

ABNORMITIES  OF  THE  URINARY  ORGANS. 


PAKT  II. 

ABNORMITIES  OF  THE  URINARY  ORGANS. 

UNDER  this  head  we  comprise  the  morbid  anatomy  of  the  kidneys  and 
the  efferent  apparatus,  viz.  the  calices,  the  bladder,  and  the  urethra  ;  the 
two  are  of  course  very  intimately  related  to  one  another.  The  abnor- 
mities of  the  suprarenal  capsules  will  be  considered  in  an  appendix. 

SECTION   I. — ABNORMITIES   OF  THE   KIDNEYS. 

§  1.  Defect-  and  Excess  of  Formation. — The  urinary  apparatus  is  very 
rarely  entirely  deficient ;  it  is  generally  found  even  in  very  imperfect 
monstrosities.  One  kidney  is  frequently  absent,  or  individual  portions 
of  the  system  are,  as  we  shall  have  occasion  to  see,  more  or  less  imper- 
fectly developed. 

When  one  kidney  only  is  present,  it  is  important  to  distinguish  between 
the  unsymmetrical  and  the  solitary  kidney.  The  former  is  represented 
by  a  right  or  left  kidney,  which  is  normal  in  regard  to  position  and  con- 
formation, and  occasionally  rather  enlarged,  its  fellow  being  deficient.  The 
solitary  kidney  is  the  result  of  a  fusion  of  the  two  organs,  and  therefore 
offers  the  characters  peculiar  to  this  arrangement  in  a  greater  or  less 
degree.  The  lowest  degree  of  fusion  is  seen  in  the  horseshoe  kidney 
(ren  unguliformis) ;  the  two  kidneys  are  united  at  their  inferior  portions 
by  a  flat,  riband-like,  or  rounded  bridge  of  tissue,  which  crosses  the  ver- 
tebral column.  In  the  higher  degrees  the  two  lateral  portions  approach 
one  another  more  and  more,  until  they  reach  the  highest  degree,  in  which 
a  single  disk-like  kidney,  lying  in  the  median  line  and  provided  with  a 
double  or  a  single  calyx,  represents  complete  fusion.  The  more  intimate 
this  union  is,  the  more  the  hilus  of  the  kidneys  is  directed  forwards,  so 
that  whereas,  in  the  lowest  degree,  it  is  indicated  by  an  evidently  in- 
creased development  of  the  posterior  labium  of  the  hilus,  the  hilus  of  the 
solitary  kidney  occupies  the  anterior  surface.  The  more  considerable  the 
fusion  is,  the  more  the  kidneys  descend  along  the  vertebral  column,  and 
the  solitary  kidney  is  commonly  situated  at  the  promontory,  or  even  at 
the  concavity  of  the  sacrum.  In  exceptional  cases  only  the  solitary 
kidney  is  placed,  like  the  unsymmetrical  kidney,  at  the  side  of  the  verte- 
bral column,  on  one  side  of  the  median  line. 

Excess  of  development  occurs  very  rarely,  except  in  the  case  of  biven- 
tral  monsters,  in  the  shape  of  a  third  kidney,  situated  in  the  median  line, 
and  generally  placed  at  the  promontory ;  or  in  the  shape  of  a  single 
symmetrical  kidney,  which  is  composed  of  two  kidneys  united  into  one. 

VOL.  II.  10 


146  ABNORMITIES    OF 

§  2.  Deviations  of  Size. — The  kidneys  are  found  enlarged  or  dimi- 
nished in  various  degrees,  and  under  various  circumstances. 

1.  Enlargement  is  observed — 

Firstly.  Occasionally  in  one  kidney,  after  its  fellow  has  been  deprived 
of  its  functions ;  this  is  a  case  of  hypertrophy  which  may  be  considered 
as  analogous  to  the  increase  of  size  in  the  unsymmetrical  kidney ; 

Secondly.  As  congestive  turgor  ; 

Thirdly.  As  inflammatory  swelling  ; 

Fourthly.  As  a  consequence  of  infiltration  of  the  renal  tissue  induced 
by  or  independent  of  inflammation ;  various  forms  of  Bright's  disease 
belong  to  this  subdivision ; 

Fifthly,  as  arising  from  morbid  growths,  in  which  case  the  enlarge- 
ment corresponds  to  their  number  and  size ; 

Sixthly.  As  originating  in  dilatation  of  the  pelvis  and  calices  of  the 
kidneys;  the  greater  in  this  case  the  increase  of  size,  the  more  will  the 
renal  substance  become  atrophied  in  consequence  of  pressure  from  within. 
Rayer  states  the  left  kidney  to  be  normally  of  greater  weight  and  larger 
dimensions  than  the  one  on  the  right  side. 

Abnormal  smallness  is  either  congenital,  or  the  result  of  atrophy. 
Spontaneous  and  primary  atrophy  occurring  independent  of  contraction, 
or  complete  occlusion  of  the  artery,  is  very  unusual,  and  belongs  almost 
exclusively  to  old  age ;  secondary  atrophy,  resulting  from  and  compli- 
cated with  disease  of  the  tissues,  is  much  more  frequent.  In  the  case  of 
extreme  dilatation  of  the  renal  pelves  and  calices  atrophy  and  enlarge- 
ment appear  combined. 

2.  Atrophy  may  affect  the  two  substances  of  the  kidney  uniformly ; 
or  it  may  involve  the  cortical  substance  only ;  the  latter  is  the  more 
frequent  case  in  secondary  atrophy,  on  account  of  the  greater  proclivity 
to  disease  in  the  cortical  substance.     The  tissue  is  rendered  pale,  or  it 
may  be  distinguished  by  its  darker  color,  and  the  vessels  are  often  found 
varicose.     We  very  often  find  an  unusual  amount  of  fat  accumulated 
round  the  atrophic  kidney. 

We  shall  have  occasion  to  enter  more  fully  into  the  subject  of  secon- 
dary atrophy,  at  a  future  period. 

§  3.  Deviations  of  Form. — Besides  the  anomalous  forms  of  the  kid- 
neys, resulting  from  fusion  of  the  two  organs,  which  we  have  already 
described,  we  may  point  to  the  lobulated  kidney  as  an  interesting  con- 
formation. It  occurs  as  an  arrest  of  development  in  the  foetal  state, 
or  if  acquired,  as  atrophy  of  the  cortical  substance,  accompanied  by 
dilatation  of  the  calices.  There  are  other  congenital  malformations  of  the 
kidneys,  which  are  of  less  importance,  as,  for  instance,  the  elongated 
kidney,  which  appertains  to  the  foetal  state,  the  round,  prismatic,  trian- 
gular, cylindrical  kidneys,  the  kidneys  with  a  transverse  furrow  (sepa- 
ration into  an  upper  and  lower  half) ;  and  also  various  acquired  mal- 
formations, which  are  caused  by  external  pressure,  by  partial  loss  of 
substance,  and  atrophy. 

§  4.  Deviations  of  Position. — Here  too  we  must  first  point  to  an 
anomaly  resulting  from  the  various  degrees  of  fusion  of  the  two  organs, 


THE    KIDNEYS.  147 

i.  e.  the  descent  of  the  kidneys  to  a  lower  part  of  the  abdomen.  This 
may,  however,  occur  independently  of  the  malformation  alluded  to,  and 
we  sometimes  find  one,  sometimes  both  kidneys,  as  low  down  as  the  brim 
of  the  pelvis,  or  even  as  the  hollow  of  the  sacrum.  The  anomalies  in 
the  origin  of  the  renal  vessels  which  correspond  to  the  original  devi- 
ation of  position  deserve  attention,  as  well  as  the  increase  in  their  num- 
ber and  the  diminution  of  the  ureter  in  proportion  to  the  descent  of 
the  kidney. 

The  kidneys,  and  especially  the  right  one,  may  be  depressed  by  an 
enlarged  liver,  and  the  consequence  is,  that  the  hilus  of  the  former  is 
turned  upwards,  as  the  upper  portion  of  the  kidney  is  necessarily  most 
depressed. 

We  have  lastly  to  allude  to  the  occasional  movability  of  the  kidneys, 
which  is  owing  to  insufficient  fixation  by  means  of  the  adipose  fascia, 
and  apparently  also  to  an  elongation  of  the  vessels ;  we  sometimes  find 
that  the  kidneys  may  be  moved  from  one  to  two  inches  along  the  spinal 
column. 

§  5.  Deviations  of  Consistency. — The  kidneys  sometimes  offer  a  dimi- 
nution of  consistency,  or  relaxation,  or  an  increase  of  resistancy  or  tough- 
ness, without  any  apparent  change  of  texture.  The  former  occurs  con- 
currently with  a  similar  condition  in  other  parenchymatous  organs,  and 
is  the  result  of  cachexia,  anaemia,  and  marasmus,  and  of  defibrination  of 
the  blood,  from  excessive  exudations ;  the  organs,  in  this  case,  are  very 
pale  and  friable.  Both  an  increase  and  a  diminution  of  consistency  are 
much  more  frequent  as  complications  of  textural  alterations,  and  we  shall 
examine  them  more  in  detail  under  this  head.  Genuine  softening  of  the 
entire  kidney,  or  of  a  portion  of  the  organ,  in  the  shape  of  spots  of  vari- 
ous sizes,  of  a  dirty  brown,  chocolate-colored,  rusty  pulp,  is  a  very  rare- 
occurrence. 

§  6.  Solution  of  Continuity. — This  is  produced  not  only  by  cutting-  in- 
truments,  but  may  occur  in  the  shape  of  rupture,  from  concussion,  or  in 
consequence  of  falls  or  blows,  received  in  the  region  of  the  kidneys. 
After  a  fall  from  a  considerable  height,  rupture  of  the  kidneys  is  very  fre- 
quently complicated  with  laceration  of  other  abdominal  viscera.  It  gives 
rise  to  hemorrhage,  inflammation,  and  suppuration  ;  the  latter  terminates 
in  the  manner  that  we  shall  have  occasion  to  delineate  when  speaking  of 
renal  abscess.  Concurrent  injury  of  the  calices  and  of  the  pelvis  of  the 
kidney,  causes  extravasation  of  urine  into  and  beyond  the  adipose  cover- 
ing of  the  kidneys :  if  the  peritoneum  has  also  suffered,  a  fatal  termina- 
tion ensues  rapidly ;  if  not,  a  permanent  or  temporary  cure,  with  a  resi- 
duary fistula,  may  follow. 

§  7.  Diseases  of  the  Tissues.  1.  Hypercemia,  apoplexy,  ancemia. — 
Hypersemia  of  the  kidneys  not  unfrequently  occurs  in  the  active  form 
accompanying  an  exaltation  of  the  renal  functions  ;  or  as  passive  conges- 
tion in  consequence  of  general  marasmus,  and  especially  in  consequence 
of  paralysis  of  the  spinal  and  ganglionic  nerves,  such  as  we  find  in  the 
torpid  condition  of  the  sympathetic  in  the  insane,  connected  with  abdo- 


148  ABNORMITIES    OF 

minal  plethora  and  congestion,  and  in  paraplegic  cases ;  it  also,  occurs  in 
the  mechanical  form  as  a  consequence  of  impeded  circulation  in  con- 
nection with  hypersemia  of  other  organs.  The  effects,  are  swelling  of 
the  organ  (congestive  turgor)  and  increase  of  size,  greater  depth  of 
color  of  the  tissues,  increased  density  and  resistancy,  and  loose  attach- 
ment of  the  fascia  propria.  In  children  the  tubular  portion  is  frequently 
the  chief  seat  of  hyperagrnia.  When  it  has  reached  a  high  degree,  it  is 
apt  to  give  rise  to  spontaneous  hemorrhage  (renal  apoplexy),  which,  both 
in  children  and  adults,  has  its  main  seat  in  the  pyramids.  We  then 
find  in  the  place  of  the  pyramids,  a  spot  of  various  dimensions,  which 
has  pushed  aside  a  proportionate  amount  of  parenchyma,  and  contains 
besides  coagulated  dark  blood,  the  broken-up  remains  of  the  tubular  sub- 
stance. A  cure  undoubtedly  ensues  occasionally ;  the  effusion  gradually 
loses  its  color,  and  assumes  a  rusty  and  a  yellow  tint ;  it  is  then  absorbed, 
and  the  calyx  becoming  obliterated,  a  fibro-cellular  cicatrix  closes  up  the 
cavity.  Minute  hemorrhagic  spots,  in  the  shape  of  ecchymoses  of  the 
tissue  resulting  from  an  acute  disorganization  of  the  blood,  as  well  as  small 
extravasations  under  the  tunica  albuginea,  are  of  much  more  frequent 
occurrence. 

Hyperssmia  accompanied  by  increase  of  size  (hypertrophy),  is,  accord- 
ing to  the  few  cases  we  have  been  able  to  examine,  the  only  anomaly  of 
the  kidney,  demonstrable  in  diabetes  by  the  pathological  anatomist. 

Anaemia  of  the  kidneys  occurs  not  only  in  connection  with  general 
impoverishment  of  the  blood,  but  it  is  found  as  a  more  or  less  character- 
istic symptom,  in  all  those  cases  in  which  the  renal  parenchyma  has 
become  impermeable  from  being  infiltrated  with  coagulable  matter,  either 
owing  to  inflammation  or  deficient  nutrition  ;  this  is  particularly  the  case 
in  that  disease  which  is  commonly  cited  as  the  type  of  the  class,  Bright's 
disease  of  the  kidney. 

2.  Inflammation. — Inflammation  of  the  kidneys  is  either  primary, 
secondary,  or  metastatic ;  in  the  first  case  it  results  from  injury,  concus- 
sion of  the  intestines,  cold,  or  specific  irritation  (turpentine,  cantharides, 
&c.)  ;  in  the  second  it  follows  acute  or  chronic  diseases,  and  it  then  pre- 
sents a  more  or  less  remarkable  type,  corresponding  to  the  general 
dyscrasia ;  in  the  third  instance  it  arises  chiefly  from  inflammations  of 
the  pelvis  and  calices,  or  from  inflammations  of  the  fascia  adiposa  and 
adjoining  organs.  The  inflammation  runs  an  acute  or  a  chronic  course ; 
the  idiopathic  variety  being  particularly  liable  to  the  former. 

The  cortical  substance  is  the  chief  seat  of  the  first  two  varieties,  as  of 
textural  alterations  generally ;  when  the  inflammation  commences  at  the 
pelves  of  the  kidneys,  the  tubular  substance  is  naturally  implicated  also. 
In  the  former  case  we  often  find  one  or  both  kidneys,  either  simultane- 
ously or  in  rapid  succession  attacked  throughout  their  substance ; 
whereas  the  latter  commences  in  spots  from  which  it  extends  through  the 
renal  tissue. 

.  The  following  are  the  anatomical  characters  of  acute  inflammation  of 
the  kidneys,  modified  of  course  by  the  degree  and  the  acuteness  of  the 
affection. 

Hyperaemic  tumefaction  and  redness  of  the  organ  are  followed  by 
a  uniform  discoloration  of  the  parenchyma  which  appears  of  a  dirty 


THE    KIDNEYS.  149 

brown  or  purple  color,  and  filled  with  a  dark  sanguinolent  fluid ;  it  is 
either  turgid  and  resistant,  or  collapsed,  flabby,  and  very  friable  ;  or  it 
may  be  turgid  and  friable,  and  the  discoloration  less  uniformly  grayish- 
red,  or  dirty  white,  accompanied  by  infiltration  of  a  denser,  coagulable, 
fibrinous  substance,  the  texture  is  granular,  the  surface  scattered  over 
with  an  injected,  asteroid,  and  polyhedral  vascular  network,  and  the 
fractured  surfaces  or  sections  made  in  the  direction  of  the  hilus,  are 
streaked  with  striated  vessels. 

The  general  result  of  the  infiltration  is,  that  the  organ  is  more  or  less 
swollen  and  discolored,  and  that  its  consistency  is  variously  diminished. 
In  accordance  with  what  has  been  above  remarked,  we  find  the  cortical 
substance  chiefly  affected ;  the  affection  is  general  or  partial,  and  in  the 
latter  case  it  occupies  particularly  the  superficial  layer  ;  in  the  first  in- 
stance the  swollen  cortical  substance  is  found  to  have  forced  its  way  into 
the  basis  of  the  pyramids,  between  the  fasces  of  the  tubuli,  and  they 
consequently  appear  unravelled  and  fimbriated. 

The  process  not  unfrequently  extends  to  the  tubular  portion  itself,  or 
the  latter  is  involved  in  the  inflammation  propagated  from  the  pelvis. 
The  pyramids  then  appear  enlarged,  swollen,  pale  ;  their  color  changed 
to  a  dirty  brown,  or  grayish-red,  and  softened  or  indurated  according  to 
the  nature  of  the  inflammatory  products ;  the  inner  membrane  of  the 
calices  and  pelvis  is  in  both  cases  injected  as  in  catarrhal  inflammations, 
reddened  and  relaxed,  and  filled  with  an  opaque,  flaky,  grayish,  or 
yellowish-brown  fluid. 

Externally  we  find  the  fascia  propria,  and  even  the  adipose  covering 
of  the  kidneys  involved  in  the  inflammatory  process  :  the  former  is  easily 
detached  from  those  portions  of  the  surface  which  present  the  vascular 
injections  above  spoken  of,  its  tissue  is  more  or  less  injected  and  tume- 
fied ;  the  latter  is  infiltrated  with  serum,  and  softened. 

This  inflammation  occasionally  affects  one  kidney  only,  but  very  often 
both  are  simultaneously  attacked :  in  the  latter  case,  especially,  it  is 
liable  to  terminate  fatally,  in  consequence  of  paralysis  of  the  renal  func- 
tion with  typhoid  symptoms,  resulting  from  retention  of  the  urea  in  the 
blood ;  this  is  frequently  complicated  with  serous  effusion  into  the  ventri- 
cles of  the  brain,  or  into  the  pulmonary  tissue,  followed  by  putrescence ; 
or  if  the  inflammation  reaches  a  certain  degree  of  intensity,  suppuration, 
or  an  excessive  retrograde  process,  or  atrophy  may  result ;  or,  lastly, 
the  affection  may  become  chronic. 

Suppuration  is  not  a  frequent  consequence.  The  inflammatory  pro- 
duct which  has  been  infiltrated  in  detached  sections,  or  uniformly 
throughout  the  organ,  is  converted  at  first  into  small  punctiform  or 
millet-sized  spots  of  white,  creamy,  or  yellow  pus,  which  subsequently 
coalesce  into  a  small  abscess.  In  its  vicinity  a  renewed  reactive  pro- 
cess is  set  up,  and  we  find  a  red  injected  halo,  varying  in  size,  which 
gives  rise  to  a  similar  fusible  product  leading  to  an  extension  of  the 
abscess.  The  original  small  abscesses  are  sometimes  found  scantily  dis- 
persed through  the  kidney,  at  others  they  are  grouped  together,  at 
others,  again,  they  are  thickly  sown  through  the  entire  kidney ;  they 
are  then  characterized  by  the  surrounding  inflammatory  halo,  and  this 
renders  them  conspicuous  though  individually  almost  imperceptible. 


150  ABNORMITIES    OF 

They  are  always  incomparably  more  numerous  in  the  cortical  substance ; 
they  here  generally  retain  their  rounded  shape,  even  whilst  enlarging, 
whereas  in  the  tubular  substance  they  are  converted  into  elongated 
striated  abscesses. 

In  the  manner  just  described,  as  well  as  by  the  coalition  of  several 
abscesses,  we  see  an  extensive  purulent  accumulation  brought  about, 
which  may  increase  so  as  to  occupy  one-half  or  two-thirds,  or  more,  of 
the  kidney.  Moreover,  there  may  be  one  or  more  of  these  accumula- 
tions, and  their  existence  establishes  phthisis  renalis. 

Renal  abscess  extends  in  the  most  various  directions  from  the  inflam- 
mation and  suppurative  fusion  spreading  through  the  kidney,  and  even 
beyond  its  sheath ;  we  most  frequently  find  it  presenting  excavations  or 
sinuses,  backwards  and  downwards ;  it  causes  death  by  exhaustion,  or  if 
the  progress  of  the  fusion  is  stopped,  the  surrounding  parenchyma  may 
become  obliterated,  or  in  the  case  when  suppuration  has  extended  be- 
yond the  latter,  the  fasciae  of  the  kidney  may  become  converted  into 
cartilaginous  tissue,  and  the  abscess  thus  be  enclosed  and  be  borne  for  a 
long  period ;  it  may  be  reduced  in  size,  and  may  even  heal  up,  leaving  a 
cicatrix  ;  this  is  particularly  liable  to  result  after  an  opening  and  a  dis- 
charge have  been  effected  in  a  favorable  direction. 

This  discharge  may  take  place : 

Firstly,  into  the  cavity  of  the  renal  pelvis  ;  the  pus  is  then  discharged 
by  the  urinary  passages  ; 

Secondly,  into  the  peritoneal  cavity ; 

Thirdly,  externally  in  the  lumbar  region,  by  means  of  sinuses  of 
various  dimensions  ; 

Fourthly,  after  previous  agglutination  of  the  intestine  to  the  walls  of 
the  abscess  and  perforation,  into  the  cavity  of  the  former ;  it  is  evident 
that  the  ascending  and  descending  colon,  and  the  sigmoid  flexure,  are 
particularly  liable  to  be  thus  involved,  and  in  second  order  the  duo- 
denum. 

Fifthly,  renal  abscess  has  also  been  seen  to  communicate  with  the 
lungs  after  perforation  of  the  diaphragm ;  its  contents  are  then  expecto- 
rated in  the  shape  of  urinous-purulent  sputa. 

These  discharges  may  sometimes  take  place  in  various  directions  at 
once  ;  a  combination  of  the  discharge  into  the  urinary  passages  with 
elimination  of  urine  by  a  false  passage — renal  fistula,  is  of  especial 
interest. 

Termination  in  gangrene  or  gangrenous  suppuration  is  extremely 
rare  ;  it  is  more  usual  to  find  acute  inflammation  passing  into  the  chronic 
form. 

Chronic  inflammation  of  the  kidney  either  commences  in  that  form, 
or  is  the  result  of  acute  inflammation,  or,  as  is  most  frequently  the  case, 
it  is  the  consequence  of  inflammation  of  the  urinary  passages,  and  espe- 
cially of  the  calculous  variety.  It  is  distinguished  from  acute  inflamma- 
tion by  a  lower  intensity  of  the  symptoms,  by  its  smaller  extent,  and  by 
the  variety  of  stages  presented  by  the  coexisting  and  consecutive  inflam- 
matory spots.  Chronic  inflammation  also  not  unfrequently  terminates 
in  suppuration,  which  is  particularly  the  case  with  the  variety  originating 
in  calculous  irritation  of  the  renal  pelvis ;  it  also  frequently  terminates 


THE     KIDNEYS.  151 

in  induration  and  obliteration  of  the  parenchyma,  or  induces  atrophy  of 
the  kidney. 

In  the  former  case  the  coagulable  portion  of  the  infiltrated  and  accu- 
mulated product  of  inflammation  is  converted  into  a  whitish,  fibro-larda- 
ceous,  cartilaginous  callus,  in  which  the  renal  parenchyma  has  entirely 
disappeared.  The  kidney  is  often  found  increased  in  bulk,  and  appears 
altered  in  shape,  from  the  irregular  accumulation  of  the  product,  giving 
rise  to  various  tuberculated  projections.  This  tissue  may  here,  as  else- 
where, subsequently  become  shrivelled  and  condensed,  and  is  also,  in 
a  few  cases,  the  seat  of  bone-earth  deposit,  osseous  transformation, 
ossification. 

Chronic  inflammation  is,  like  the  acute  form,  frequently  followed  by 
atrophy  of  the  kidney  ;  inasmuch  as  not  only  its  product  but  the  original 
tissues  themselves  become  absorbed.  This  secondary  atrophy  attacks 
either  the  entire  kidney  or  sections  of  the  organ,  and  the  consequence 
is,  accordingly,  a  uniform  reduction  of  its  size,  or  a  partial  contraction, 
which  gives  the  kidney  a  shrivelled  and  uneven,  lobulated  surface.  The 
contraction  sometimes  advances  to  such  a  degree,  that  the  kidney  appears 
reduced  to  the  size  of  a  hen's  or  even  a  pigeon's  egg,  it  is  surrounded 
by  the  tunica  albuginea,  that  has  become  thickened  by  the  inflamma- 
tory deposit,  and  by  contraction,  and  forms  a  callous  sheath  of  several 
lines  in  thickness  ;  on  closer  examination  we  find  the  cortical  substance 
reduced  to  a  mere  vestige  ;  the  pyramids  are  diminished  to  a  size  corre- 
sponding to  the  dimensions  of  the  organ  ;  the  tissue  generally  is  of  a 
pale-red,  or  here  and  there  of  a  slate-gray  color,  denser,  tough,  and 
fibro-cellular ;  occasionally,  however,  it  is  unusually  dark-red,  vascular, 
and  congested,  and  all  the  vessels  dilated.  The  calices  and  pelves  are 
uniformly  enlarged,  the  ureters  contracted,  their  parietes  shrivelled  and 
thickened,  and  here  and  there  approaching  to  obliteration,  or  actually 
obliterated. 

Inflammation  of  the  kidneys,  with  its  consequences,  has  occasionally 
been  discovered  in  new-born  infants  ;  but  its  frequency  and  importance 
are  much  more  considerable  at  maturity  and  at  the  advanced  periods 
of  life. 

3.  Bright* s  Disease  of  the  Kidney. — This  affection  of  the  kidneys, 
which  has  been  named  after  its  discoverer,  Bright,  and  has  of  late  been 
extensively  investigated,  is  of  extreme  importance.  It  has  been  termed 
granular  degeneration,  by  Christison,  and  nephrite  albumineuse,  by 
Rayer.  "We  treat  of  it  in  connection  with  inflammatory  affections  of 
the  organ,  for  reasons  which  will  appear  in  the  sequel. 

It  is  generally  a  chronic  disease  ;  however  there  are  numerous  cases 
that  incline  to  an  acute  course,  and  some  equal,  or  even  exceed,  acute 
inflammation  in  rapidity. 

It  assumes  very  different  forms,  which  have  reference  either  to  the 
degree  and  rapidity  of  the  disease,  or  to  its  stage  of  development ;  the 
former  bear  a  close  relation,  first,  to  the  amount  of  local  reaction  in 
the  renal  tissue,  and,  secondly,  to  the  dyscrasic  state  of  the  blood.  We 
shall  commence  by  describing  the  various  phases  which  the  disease  pre- 
sents as  distinct  forms ;  we  shall  then,  examine  its  complications,  their 
course,  stages,  degrees,  and  transitions,  and  lastly,  arrive  at  a  general 
analysis  of  the  disease. 


152  ABNORMITIES    OF 

The  cortical  substance  is  that  which  is  primarily  and  chiefly  affected ; 
in  the  course  of  the  disease,  however,  the  tubular  substance  also  becomes 
involved  in  the  manner  which  will  be  immediately  delineated. 

First  form. — The  kidney  appears  enlarged,  swollen,  heavier  ;  the  cor- 
tical tissue  is  almost  uniformly  infiltrated  with  dirty  brownish-red,  turbid 
fluid,  and  the  bloodvessels,  with  the  tissue  immediately  surrounding  them, 
are  delineated  on  this  background  in  the  shape  of  spots,  or  streaks  of  a 
darker  red.  Other  red  spots  may  be  visible,  which  are  owing  to  extra- 
vasations of  blood  into  the  tissue, — ecchymoses.  The  pyramids,  how- 
ever, present  a  similar  though  darker  discoloration,  with  dull-red  striae. 
The  entire  parenchyma,  but  more  especially  the  cortical  substance,  is 
peculiarly  pulpy  and  friable,  and  the  surface,  presented  by  section  or 
fracture,  yields  a  reddish-brown,  limpid,  delicately  flocculent  and  opaque, 
sanguinolent  and  slightly  viscid  fluid.  The  organ  generally  is  charac- 
terized by  a  turgid  though  flabby  state.  The  fascia  propria,  from  the 
injected  state  of  its  vessels,  but  more  from  the  exudation  of  blood  into 
its  tissue,  is  of  a  dirty  red  color,  and  is  easily  detached ;  the  mucous 
membrane  of  the  calices  and  pelvis  is  similarly  reddened  and  tumefied  ; 
and  their  cavity  contains  a  thin,  muco-sanguinolent,  turbid,  urinous  fluid. 

Second  form. — Besides  the  increase  in  size  and  weight  found  in  the 
first  variety,  the  cortical  substance  presents  an  infiltration  of  a  grayish 
or  grayish-red,  or  yellow,  viscid,  and  turbid  fluid,  which  pervades  it  uni- 
formly or  in  diffused  spots ;  the  color  of  the  tissue  corresponds,  and  if 
more  carefully  examined,  an  indistinct,  dotted,  or  linear  arrangement  is 
perceived.  At  the  same  time,  small  punctiform  or  striated  ecchymoses 
are  found,  which  are  the  more  conspicuous  the  paler  the  color  of  the  in- 
filtrated tissue.  The  tissue  frequently  presents  the  infiltrated  and  pallid 
appearance  in  some  parts,  whilst  the  hypersemia  and  ecchymoses  predo- 
minate in  others ;  this  constitutes  the  combination  of  partial  anaemia 
and  hypersemia,  alluded  to  by  authors  as  a  special  variety.  The  organ 
appears  of  diminished  firmness,  but  this  character  is  less  marked  here 
than  in  the  first  form.  The  renal  fascia  observes  the  same  bearing,  the 
mucous  membrane  of  the  pelvis  and  calices  of  the  kidney  is  of  a  roseate 
hue,  and  tumefied ;  and  the  latter  contain  a  flocculent,  turbid,  yellowish 
or  reddish-white  fluid. 

Third  form.  —  There  is  considerable  enlargement  and  increase  in 
weight ;  the  cortical  substance  is  completely  anaemic ;  and  only  a  few 
solitary  dilated  vessels,  bearing  an  asteroid,  convoluted,  or  striated  ap- 
pearance, are  seen  in  it.  The  cortical  portion  presents  an  increase  in 
diameter  of  from  five  to  nine  lines ;  its  surface  is  smooth  and  slightly 
glossy;  it  is  tense,  friable,  and  infiltrated  with  a  large  quantity  of 
opaque,  milky-white,  or  yellowish  fluid.  The  superficial  layer  more  par- 
ticularly, but  also  the  deeper-seated  parts,  are  found  to  be  made  up  of 
white  or  yellowish-white,  loose,  tense  granules  (Bright's  granulations), 
of  the  size  of  a  poppy-seed,  or  a  pin's  head  ;  in  the  neighborhood  of  the 
pyramids  these  granulations  assume  a  linear  appearance. 

The  increase  of  the  cortical  substance  either  extends  to  the  base  of 
the  pyramids  only,  or  affects  those  portions  also  that  dip  down  between 
the  latter ;  by  this  means  the  pyramids,  and  more  particularly  their 
apices,  become  compressed.  The  pyramids  are  of  a  pale-red  color,  and 


THE    KIDNEYS.  153 

from  the  granular  cortical  substance  forcing  its  way  between  the  tubuli 
and  separating  them,  the  basis  of  the  pyramids  presents  a  frayed  or  un- 
ravelled appearance,  resembling  a  plume  with  dependent  feathers,  or  a 
sheaf  of  wheat. 

The  renal  fascia  is  easily  detached  ;  its  tissue  is  swollen  and  opaque, 
the  mucous  membrane  of  the  calices  and  pelvis  of  the  kidney  is  red- 
dened, and  there  is  a  milky,  turbid,  viscid  fluid  in  their  cavities. 

Fourth  form. — The  increase  in  size  and  weight  is  very  considerable, 
and  the  consistency  of  the  tissues  is  much  diminished ;  the  cortical  sub- 
stance is  very  tense,  and  here  and  there  appears  almost  fluctuating  ;  its 
tissue  is  completely  anaemic  and  very  friable,  and  gorged  with  a  large 
quantity  of  milky-white  or  yellowish  juice.  The  granulations  exceed 
the  size  of  millet-seeds,  and  equal  that  of  hemp-seeds ;  and  as  this  en- 
largement is  chiefly  effected  in  the  peripheral  layer,  they  project  from 
the  surface  of  the  organ,  and  give  it  a  racemose  appearance.  Occa- 
sionally, we  find  this  increase  of  size  occurring  with  great  rapidity  in 
sections,  and  we  then  have  an  accumulation  of  granulations  shooting 
like  a  cauliflower  from  the  surface,  and  producing  irregularities  and 
nodulated  protuberances  upon  the  kidney.  The  granulations  are  very 
soft,  tear  and  dissolve  upon  the  slightest  touch ;  the  renal  sheath  is 
almost  unattached,  the  pyramids  are  of  a  pale-red  color  and  undefined, 
and  the  reddened  calices  and  pelves  contain  a  viscid  creamy  fluid. 

Fifth  form.— The  kidneys  are  enlarged  or  of  the  normal  size,  or  they 
may  be  reduced  in  size ;  their  surface  is  granular  and  racemose,  or 
whilst  certain  portions  present  the  nodulated  and  prominent  appearance, 
others  are  irregularly  furrowed,  indented,  and  cicatriform.  The  cortical 
tissue  is  coarsely  granulated,  looser  in  texture,  very  vascular  and  con- 
gested, and  the  vessels  are  varicose  ;  or  else  we  find  it,  as  in  the  case  of 
a  diminution  of  the  organ,  of  pale-yellow  or  ashy  hue,  exsanguineous, 
of  coriaceous  density,  and  mainly  of  a  fibro-cellular  texture  ;  the  inden- 
tations at  the  surface  here  and  there  present  a  similar  tissue,  of  a 
whitish  or  slaty  color.  We  also  not  unfrequently  see  cysts,  containing 
the  most  various  substances,  and  varying  in  size  from  that  of  a  poppy- 
seed  to  that  of  a  pea  or  nut  and  more,  scattered  through  the  cortical 
structure. 

In  the  former  case  the  attachment  of  the  fascia  propria  is  slight,  in 
the  second  it  is  more  intimate  :  the  fascia  is  thickened,  and  the  adipose 
layer  indurated.  The  pyramids  are  small  and  atrophied,  of  increased 
density,  and  generally  of  a  dirty  brown  color  ;  the  calices  and  pelvis  are 
slightly  contracted. 

Sixth  form. — The  organ  is  but  little  increased  in  size  and  weight,  the 
cortical  substance  only  presents  a  few  undefined  patches  of  a  paler  color, 
and  the  prevailing  hue  is  either  pale  red,  or  it  is  found  on  closer  examina- 
tion to  offer  transitions  of  a  pale  red,  a  white,  yellow,  or  ashy  color.  It  is 
infiltrated  with  inspissated  matter,  resembling  thick  cream  or  coagulated 
albumen  ;  and  not  only  does  not  present  greater  laxity  of  texture,  but  is 
of  the  normal  or  even  of  increased  consistency. 

The  fascia  propria  is  but  slightly  less  adherent  at  these  points  than  in 
the  healthy  condition,  and  the  pyramids,  as  well  as  the  calices  and  pelvis, 
are  normal. 


154  ABNORMITIES    OF 

Seventh  form. — The  increase  of  size  is  commonly  trifling  ;  occasionally 
there  is  partial  atrophy  and  diminution.  There  is  increase  of  density 
and  consistency.  As  in  the  last  variety,  the  cortical  substance  only 
presents  patches  of  a  dull  white  color,  which  have  no  defined  borders,  and 
are  often  very  extensive ;  it  arises  from  a  coagulated,  albuminous,  larda- 
ceous-looking  substance,  in  which  no  trace  of  the  renal  tissue  remains. 
We  here  find  considerable  swelling  of  the  kidney,  owing  to  the  copious 
deposition  of  the  morbid  growth  ;  or  the  organ  otherwise  seems  shrunk, 
and  presents  the  appearance  and  consistency  of  fatty  cartilaginous  tissue. 
One  or  more  of  the  pyramids  occasionally  undergo  a  similar  metamor- 
phosis. The  fascia  propria  is  agglutinated  to  the  diseased  portions  of 
the  kidney,  and  thickened ;  the  lining  membrane  of  the  calices  and  pelvis 
is  tumefied. 

Eighth  form. — The  kidney  presents  but  a  slight  increase  of  size,  or  is 
of  normal  dimensions,  but  always  considerably  indurated.  The  general 
hue  is  a  dirty  red  or  brownish-yellow,  and  the  cortical  substance  pre- 
sents a  fatty  waxy  gloss,  is  unusually  hard  and  brittle,  and  infiltrated 
with  an  albuminous,  lardaceous,  and  transparent  substance.  Occa- 
sionally a  whitish  flocculent  deposit  is  seen  in  the  tissue,  of  the  shape  of 
fine  granular  dots  and  lines,  giving  to  the  surface  and  sections  a  marbled 
appearance. 

We  have  thus  enumerated  the  forms  which,  in  a  general  point  of  view, 
we  think  it  proper  to  class  under  Bright's  disease.  The  first  seven  forms 
undoubtedly  belong  to  the  latter,  if  the  totality  of  the  symptoms,  as  they 
appear  in  the  living  subject,  be  considered :  they  also  occur  complicated 
with  one  another,  and  the  second,  third,  fourth,  and  fifth  forms  more 
particularly  represent  Bright's  disease  and  Christison's  granular  degene- 
ration of  the  kidney.  In  the  latter  form  the  disease  is  generally  chronic, 
though  with  an  acute  tendency  and  occasionally  exacerbations ;  the  se- 
cond, third,  and  fourth  forms  represent  progressive  stages  of  degrees  of 
the  metamorphosis  occurring  in  Bright's  disease  :  they  vary  in  duration, 
and  pass  from  one  to  the  other  either  gradually  or,  as  is  frequently  the  case, 
with  very  tumultuous  symptoms.  Each  of  these  stages  may  prove  fatal. 
The  fifth  form  is  the  last  link  of  the  metamorphosis  ;  with  it  the  process 
becomes  retrograde,  and  the  disorganized  tissue  of  the  viscus  presents 
the  condition  of  secondary  atrophy.  The  different  varieties  are  not  un- 
frequently  complicated  with  one  another ;  and  we  thus  find  the  first  de- 
gree (second  form)  attacking  one  kidney,  or  a  section  of  one  kidney, 
whilst  the  other  kidney,  or  the  other  sections,  present  the  metamorphosis 
of  the  third  or  fourth  degree  (third  and  fourth  form).  The  peripheral 
layer  of  the  cortical  substance  is  generally  in  a  more  advanced  stage  than 
the  deeper-seated  layers. 

The  sixth  and  seventh  forms  represent  the  less  frequent  or  chronic 
varieties  of  the  disease ;  the  latter  (the  seventh)  must  be  looked  upon  as 
the  terminal  point  of  the  metamorphosis,  as  the  product  of  the  disease  is 
retained  in  a  state  of  condensation  and  organization,  and  subsequently 
shrivels  up.  It  is  sometimes  complicated  with  the  varieties  previously 
spoken  of. 

The  first  form  is  extremely  rare,  and  runs  an  acute  course ;  on  the 
occurrence  of  powerful  exciting  causes,  very  tumultuous  symptoms  are 


THE    KIDNEYS.  155 

sometimes  induced,  which  speedily  reach  their  climax,  and  may  termi- 
nate fatally  on  the  fourteenth  day. 

The  eighth  form  is  invariably  chronic  ;  we  shall  for  the  present  exclude 
its  consideration  from  the  following  remarks,  and  advert  to  it  subse- 
quently, for  reasons  that  will  then  be  apparent. 

The  nature  of  the  disease,  and  the  scientific  exposition  of  its  charac- 
teristic symptoms,  have  been  the  subject  of  numerous  discussions,  and 
we  neither  venture  to  assume  that  our  remarks  will  add  great  weight  to 
the  arguments  of  those  who  consider  it  inflammatory,  nor  do  we  wish  to 
anticipate  further  investigations  and  statements  of  depth  and  originality. 

We  consider  the  nature  of  Bright's  disease  to  consist  in  an  inflamma- 
tory process,  which  proceeds  from  a  stage  of  hypersemia  to  one  of  stasis, 
and  then  gives  rise  to  a  product,  which  is  not  only  remarkable  by  its 
peculiar  character,  but  which,  in  well-marked  cases,  by  its  excessive  accu- 
mulation, causes  a  singular  alteration  in  the  appearance  and  structure  of 
the  kidney.  It  commonly  runs,  as  we  have  already  stated,  a  chronic 
course,  with  occasional  exacerbations,  but  it  is  sometimes  acute.  In  the 
latter  very  important  cases,  in  which,  from  the  tumultuous  violence  of 
the  exudation,  the  product  is  mixed  with  a  large  amount  of  serum,  and 
is  generally  reddened  by  the  coloring  matter  of  the  blood,  and  in  which 
the  characteristic  milky  or  creamy  or  coagulated  substance  of  well- 
marked  Bright's  disease  is  not  formed,  we  should  be  obliged  to  consider  the 
condition  as  one  of  very  acute  simple  inflammation  of  the  kidneys,  were 
it  not  that  the  characteristic  general  symptoms  and  the  constitution  of 
the  urine  established  it  as  a  case  of  Bright's  disease. 

The  whitish  or  ashy,  milky  or  creamy  product,  which  may  resemble 
albumen  in  its  various  degrees  of  coagulation,  and  consists  of  solitary 
and  accumulated  molecules,  or  of  more  or  less  globular  fibrinous  coagula 
and  pus-corpuscles  (Gluge),  is  an  albumino-fibrinous  substance,  with  a 
predominance  of  albumen ;  the  amount  in  which  it  occurs  is  proportioned 
to  the  amount  of  granular  degeneration. 

The  product  may,  as  in  simple  inflammation,  be  deposited  at  every 
point  of  the  renal  parenchyma  external  to  the  vessels,  but  we  find  it 
more  particularly  in  the  Malpighian  bodies  (glands),  and  subsequently 
in  the  urinary  tubuli;  the  granulations  of  Bright's  disease  are  therefore 
in  reality  the  Malpighian  corpuscles  charged  with  the  above-named 
substance.  The  more  the  latter  accumulates,  the  more  it  interferes  with 
the  circulation,  hence  the  peculiar  pallor  or  anaemic  condition  of  the 
organ. 

The  cause  of  the  peculiar  character  of  the  product  is  the  more  obscure, 
since  the  question  is  generally  evaded.  As  the  amount  of  reaction  that 
takes  place  in  the  renal  tissue  does  not  suffice  to  explain  it,  we  are  led 
to  seek  the  cause  in  an  anomalous  constitution  of  the  blood,  consisting  in 
an  excess  of  albumen,  which  may  originate  in  a  decomposition  of  the 
fibrine.  This  becomes  the  more  probable,  when  we  consider  that  the 
most  frequent  exciting  cause  (cold)  appears  peculiarly  adapted  to  give 
rise  rather  to  a  change  in  the  blood,  than  to  a  disease  of  the  kidneys, 
and  that  the  infiltration  of  the  kidney,  which  we  have  examined  as  the 
eighth  form,  is  evidently  developed  as  a  sequel  of  the  cachexise  which 
we  shall  shortly  investigate,  and  in  complication  with  similar  affections 


156  ABNORMITIES    OF 

of  other  organs  (liver,  spleen).  Although  we  might  offer  numerous  ob- 
servations on  this  connection,  the  real  cause  of  the  development  of  the 
renal  disease  from  the  crasis  of  the  blood,  which  often  takes  place  with 
such  extreme  rapidity,  is  to  us  an  enigma.  We  look  upon  the  anoma- 
lous condition  of  the  blood  in  Bright's  disease  as  the  primary  affection, 
which,  from  a  peculiar  relation  to  the  kidneys,  is  followed  by  the  se- 
condary and  visible  disorganization  of  the  renal  tissue ;  this  need  not 
however  always  ensue,  at  all  events  it  does  not  follow  as  rapidly  as  the 
structural  disease  of  the  kidney,  consequent  upon  the  vegetative  dis- 
turbance that  causes  diabetes  mellitus.  By  this  means  we  explain  how 
it  happens  that  the  two  kidneys  are  generally  attacked  at  the  same  time 
or  at  brief  intervals.  Graves  is  of  opinion  that  the  change  of  texture  is 
induced  by  the  free  acids  of  the  urine  (phosphoric  and  nitric  acids)  coa- 
gulating the  albumen  as  it  passes  into  the  urinary  tubuli. 

Bright's  disease  is  distinguished  in  the  dead  and  the  living  subject 
by  the  following  symptoms  : 

a.  We  may  briefly  enumerate  the  following  as  occurring  in  well-marked 
cases  in  the  kidneys  themselves, — increase  in  the  size  and  weight  of  the 
organ,  and  especially  of  the  cortical  substance  (the  hypertrophy  of 
French  authors,  a  term  which  may  easily  give  rise  to  a  misapprehension) ; 
anaemia,  pallor,  laxness  of  the  tissues,  development  of  peculiar  granula- 
tions, inflammatory  sympathy  of  the  renal  fascia,  on  the  one  hand,  and 
of  the  mucous  membrane  of  the  pelvis  and  calices,  on  the  other. 

/?.  The  so-called  consecutive  symptoms :  a  constant  and  considerable 
amount  of  albumen  in  the  urine,  accompanied  by  a  diminution  of  its  spe- 
cific gravity  (Gregory),  a  symptom  considered  by  Kayer  as  belonging  to 
the  chronic  form  only  ;  a  reduction  of  the  solid  constituents,  viz.  the  salts 
and  urea,  a  milky  turbid  appearance,  or  if  tinged  with  blood  and  blood- 
corpuscles,  dark  discoloration,  eminent  serosity  of  the  blood  arising  from 
the  removal  of  the  albumen,  and  accompanied  by  a  diminished  specific 
gravity  of  the  serum ;  dropsy,  which  is  chiefly  manifested  as  anasarca, 
marked  pallor  of  the  surface,  and  secondarily  as  serous  effusion  into  the 
serous  cavities,  and  especially  of  the  pleura  and  peritoneum.  Of  the 
latter  symptoms  the  albuminuria  and  the  dropsy  have  long  since  been 
the  special  objects  of  explanatory  attempts. 

Albuminuria  is  considered  by  Gregory  as  pathognomonic  only  when  the 
specific  gravity  is  simultaneously  diminished  ;  it  seems  to  ourselves  to 
consist  in  a  disturbance  of  the  catalytic  function  of  the  kidney  arising 
from  the  homologous  infiltration  of  the  renal  tissue  ;  albumen  is  in  part 
deposited  in  the  channels  of  the  urinary  tubuli  themselves,  as  a  product 
of  the  reaction.  There  is  not,  however,  a  proportionate  relation  between 
the  degree  of  the  albuminuria  and  the  amount  of  renal  disease,  as  we  may 
even  find  the  former  existing  without  the  latter. 

Sabatier,  whose  views  are  not  materially  controverted  by  Rayer's  ob- 
jection, attributes  the  dropsical  affections  to  an  attenuation  of  the  blood 
produced  by  the  removal  of  the  albumen.  This  crasis  of  the  blood  must, 
therefore,  be  viewed  as  secondary. 

The  lower  degrees  of  Bright's  disease  are  curable  by  resolution,  without 
leaving  any  traces,  like  other  moderate  inflammatory  processes.  In  the 
advanced  stages  a  cure  may  be  effected,  but  only  with  considerable  altera- 


THE    KIDNEYS.  157 

tions  of  texture,  as  manifested  in  atrophy  of  the  kidney  with  a  racemose 
surface,  varicosity  of  the  vessels,  cellulo-fibrous  condensation  of  the  tissue, 
fibro-lardaceous  thickening  of  the  renal  fascia,  and  contraction  of  the 
pelvis  and  calices,  in  induration  of  the  product,  and  its  conversion  into  a 
contractile  callus.  A  fatal  termination  is  induced,  with  a  greater  or  less 
rapidity,  by  dropsy,  and  especially  by  serous  accumulations  in  the  large 
cavities  of  the  body,  by  the  slow  or  sudden  supervention  of  serous  effu- 
sion into  the  ventricles  of  the  brain,  into  the  cerebral  substance,  and  into 
the  pulmonary  parenchyma,  by  anaemia,  by  the  retention  of  urea  in  the 
blood,  or  by  morbid  conditions  of  other  tissues  and  organs,  which  present 
accidental  or  essential  complications  with  the  renal  disease  and  its  pre- 
disposing cause. 

In  the  case  of  retention  of  urea  in  the  blood,  the  resulting  symptoms 
are  owing  to  the  antagonism  between  the  urea  and  the  nervous  matter  ; 
they  consist  in  coma,  delirium,  convulsions,  and  tetanus,  and  are  not  un- 
frequently  caused  by  urinous  effusions  within  the  cavity  of  the  cranium. 

The  complications  are  chiefly  dependent  upon  causes  that  operate  sud- 
denly or  repeatedly,  and  for  a  considerable  period,  such  as  catarrhs,  and 
particularly  bronchial  catarrh,  rheumatism,  with  or  without  endocarditis, 
and  their  sequels  ;  the  complications  may  also  originate  in  the  secondary 
disorganization  of  the  blood,  and  here  again  we  meet  with  catarrhs,  and 
also  with  extensive  exudative  processes,  both  on  the  mucous  membranes 
(serous  diarrhoea,  pneumonia),1  and,  more  especially,  on  the  serous  mem- 
branes, the  arachnoid,  pleura,  peritoneum,  and  internal  coat  of  the  blood 
vessels  (phlebitis).  Hemorrhage  and  apoplexy  are  of  rarer  occurrence. 
There  is  great  difficulty  in  accounting  for  the  complication  with  granular 
liver,  and  with  the  ascites  resulting  from  the  latter  affection.  The  super- 
vention of  Bright's  disease  as  a  new  complication  may  probably  be  ac- 
counted for  by  the  greater  liability  of  a  previously  diseased  subject  to 
the  reception  of  noxious  influences,  whether  operating  continuously  or 
temporarily  ;  we  allude  more  particularly  to  the  abuse  of  spirituous  liquors, 
and  to  cold. 

The  commonest  and  most  evident  cause  of  Bright's  disease  is  cold,  the 
sudden  or  constant  influence  of  cold  damp  air,  more  especially ;  at  all 
events,  the  occurrence  of  Bright's  disease  after  scarlatina  in  children  and 
adults,  is  most  frequently  due  to  this  cause ;  the  abuse  of  spirituous 
liquors  is  also  considered  as  a  cause,  though  chiefly  in  connection  with  the 
previously  mentioned  influences ;  diuretics,  though  they  do  not  originate, 
undoubtedly  promote  the  disease. 

Numerous  dyscrasic  momenta  are  of  considerable  importance.  We 
advert  to  the  development  of  Bright's  disease,  subsequent  to  exanthe- 
matic  fevers,  particularly  scarlatina,  to  typhus,  to  tubercular  disease  and 
tubercular  suppuration,  e.  g.  pulmonary  phthisis,  to  cancerous  diathesis, 
and  to  the  affections  which  we  are  about  to  consider  in  connection  with 
the  eighth  form. 

The  eighth  form  invariably  sets  in  without  reaction,  and  springs  from 
inveterate  scrofulous  or  rickety  disease,  but  especially  from  syphilitic 
and  mercurial  taint.  It  presents  itself  as  a  constitutional  infiltration  of 

1  [Qy.  Bronchitis?— ED.] 


158  ABNORMITIES    OF 

the  kidney,  and  is  associated  with  analogous  affections  of  the  spleen  and 
liver,  in  the  shape  of  lardaceo-albuminous  infiltration ;  both  the  nature  of 
this  product  and  the  anomalies  of  the  blood  and  the  urine  as  yet  remain 
a  perfect  enigma.  We  have  once  noticed  the  complaint  as  a  sequel  of 
intermittent  fever  combined  with  a  similar  condition  of  the  spleen. 

4.  Deposits  in  the  kidneys. — The  same  circumstances  that  give  rise  to 
deposits  or  metastases  in  the  lungs,  the  liver,  and  the  spleen,  may  induce 
them  in  the  kidneys.  They  follow  inflammations  of  the  endocardium, 
and  of  the  lining  membrane  of  the  vessels  brought  on  by  infection  of  the 
blood,  arising  from  absorption  of  the  inflammatory  product,  or  they  re- 
sult from  suppuration  and  gangrene  of  membranous  and  parenchymatous 
tissues  produced  in  a  similar  manner,  or  lastly  they  originate  in  sponta- 
neous pyaemia.  We  would  again  direct  especial  attention  to  the  deposits 
arising  from  endocarditis,  as  they  have  not  only  been  overlooked,  in  the 
same  way  as  those  occurring  in  the  spleen  have  been,  by  the  most  dis- 
tinguished inquirers,  but  as  of  late  Rayer  has  interpreted  them  falsely, 
and  has  viewed  them  as  symptoms  of  rheumatic  nephritis. 

They  are  found  in  endocarditis,  generally  coexistent  with  similar  de- 
posits in  the  spleen,  consequent  upon  primary  phlebitis  with  a  purulent 
exudation,  or  upon  the  absorption  of  pus  or  sanious  matter  from  ulcera- 
ting surfaces  or  abscesses ;  they  co-exist  with  deposits  in  the  lungs,  the 
liver,  the  brain,  the  subcutaneous,  and  intermuscular  cellular  tissue,  the 
interstitial  cellular  layers  of  the  intestines,  and  with  secondary  phlebitis, 
in  the  most  different  portions  of  the  venous  system. 

There  may  be  only  a  few,  and  in  endocarditis  we  generally  find  one 
only,  or  they  are  as  under  the  last-named  conditions,  very  numerous ;  in 
rare  cases  the  kidney  is  entirely  gorged  with  them. 

They  occur  chiefly  in  the  cortical  substance,  and  here  again  mainly  in 
its  peripheral  strata ;  so  that  they  are  at  once  apparent  on  the  removal 
of  the  fascia  albuginea ;  it  is  only  in  exceptional  cases,  and  when  they 
are  very  numerous,  that  they  occur  in  the  pyramids.  They  vary  much 
in  size,  from  that  of  an  almost  imperceptible  poppy-seed,  to  that  of  a 
millet-  or  hemp-seed,  of  a  pea,  a  bean,  or  of  a  walnut ;  the  larger  ones 
present  the  peculiar  form  described  in  the  section  on  the  spleen,  as  exhi- 
biting a  pyramidal  shape,  the  base  of  which  is  directed  towards  the  sur- 
face, the  apex  towards  the  interior  of  the  organ ;  the  smaller  ones  appear 
as  rounded  nodules.  The  intermediate  sizes  are  the  most  frequent,  but 
when  very  numerous,  they  generally  remain  so  small  as  scarcely  to  exceed 
the  size  of  millet-seeds. 

They  commence  in  the  renal  parenchyma  as  dark-red  indurated  spots, 
which  correspond  in  extent  to  the  above-mentioned  sizes ;  they  gradually 
assume  a  dirty  brown,  yellow,  or  yellowish-white  color,  and  are  surrounded 
by  a  light-red  inflammatory  halo,  which  indicates  the  reaction  set  up  in 
the  adjoining  tissue,  or  if  the  disorganization  advances  to  a  high  degree, 
by  a  dark-red,  discolored  ecchymosis.  The  latter  appearance  is  coinci- 
dent with  a  very  large  number  of  the  deposits,  and  as  we  have  seen  that 
these  must  then  be  very  small,  we  find  the  renal  tissue  presenting  in  the 
advanced  stage  of  the  disease  very  numerous  small  red  spots,  in  the  centre 
of  which  an  almost  imperceptible  yellowish-white  spot  is  discovered. 

The  further  progress  of  the  disease  consists  in  a  conversion  of  the  de- 


THE    KIDNEYS.  159 

posit  into  a  purulent  or  sanious  fluid,  and  the  abscess  may  be  enlarged 
by  an  analogous  transformation  of  the  inflammatory  halo ;  the  metamor- 
phosis may,  however,  be  benignant,  and  the  deposit  become  pale,  and 
shrivel  up  ;  it  may  then,  together  with  the  involved  tissues,  be  absorbed, 
or  partially  retained  as  a  pulpy  or  cretaceous  mass,  having  a  cicatriform 
cavity  with  a  fibro-cellular  investment,  or  a  fibro-cellular  callus,  which 
corrugates  and  draws  down  the  surrounding  parts ;  a  greasy  yellow  sub- 
stance or  chalky  concretion  is  found  buried  in  the  callus,  and  like  the 
investment  of  the  first-mentioned  cavity,  this  is  agglutinated  to  the  tunica 
albuginea. 

The  deposit  is  essentially  an  exudative  process,  the  product  of  which 
undergoes  the  described  metamorphoses ;  or  it  depends  upon  stasis  and 
coagulation  of  the  blood  in  the  capillary  vessels,  and  a  conversion  of  the 
fibrine  in  the  manner  above  described, — a  secondary  angioitis  (phlebitis) 
capillaris.  Both  metamorphoses  are  known  to  be  induced  by  something 
that  is  taken  up  by  the  blood ;  and  we  thus  generally  see  deposits  in  the 
kidneys  resulting  from  endocarditis,  which  go  through  the  second  meta- 
morphosis, and  heal  with  loss  of  substance  of  a  small  section  of  the  corti- 
cal tissue. 

In  the  case  of  solitary  deposits,  the  parenchyma,  with  the  exception 
of  that  adjoining  the  morbid  product,  does  not  participate  in  the  local 
process ;  when  they  are  very  extensive,  reaction  takes  place  throughout 
the  organ,  and  is  evidenced  by  tumefaction,  enlargement,  softening,  and 
and  infiltration  of  the  parenchyma ;  even  the  mucous  membrane  of  the 
urinary  passages  appears  congested,  reddened,  and  softened. 

5.  Morbid  growths,  a.  Fatty  deposit  in  the  kidneys. — We  shall  exa- 
mine this  subject  under  the  head  of  Hypertrophy  of  the  Fascia  Adiposa. 

b.  Formation  of  cysts. — Although  we  explicitly  exclude  the  considera- 
tion of  all  encysted  tumors  which  have  their  origin  in  a  dilatation  of  the 
urinary  passages,  and  especially  of  the  calices,  we  think  it  necessary  at 
this  place  to  discuss — 

a.  Cysts,  that  occur  frequently  in  the  renal  parenchyma,  and  which  we 
cannot  positively  state  to  be  new  formations.  We  allude  to  cysts  which 
vary  in  size  from  that  of  a  millet-seed,  pea,  or  bean,  to  that  of  a  walnut 
or  even  a  goose's  egg,  and  which  contain  a  clear,  colorless,  or  yellowish, 
serous,  alkalescent  matter,  or  a  substance  of  a  yellowish  or  brownish 
color,  and  of  a  melicerous  or  mucilaginous  consistency,  or  again,  of  a 
lateritious,  chocolate-colored  or  inky  (melanotic)  tint.  They  are  formed 
by  a  serous  membrane,  in  which  a  branched  vascular  network  may  be 
traced.  They  vary  in  number ;  sometimes  there  is  a  solitary  cyst  of  one 
of  the  above-named  sizes  ;  generally  there  are  several  of  different  sizes  ; 
and  in  rare  cases,  they  are  so  numerous,  that  the  kidney,  being  propor- 
tionately enlarged,  appears  converted  into  a  collection  of  cysts  varying 
both  as  to  size  and  to  contents,  the  renal  tissues  having  given  way  to 
them.  In  very  well-marked  cases  a  diminution  of  the  urinary  secretion, 
and  its  consequences,  have  been  observed.  These  cysts  are  chiefly  de- 
veloped in  the  peripheral  layer  of  the  cortical  substance,  and  project 
above  the  surface  of  the  kidney,  so  as  to  be  at  once  perceptible  on  the 
removal  of  the  tunica  albuginea. 

They  occur  at  every  period  of  life,  and  are  sometimes  even  congenital. 


160  ABNORMITIES    OF 

They  acquire  additional  importance  if  developed  in  consequence  of  renal 
inflammation,  especially  when  this  arises  from  lithiasis,  and  more  par- 
ticularly in  consequence  of  Bright's  disease. 

Our  own  view,  and  that  of  German  authors  generally,  is  that  they  are 
not  the  dilated  terminations  of  the  Malpighian  capillary  tubes,  but  that 
they  consist  in  a  conversion  of  the  cellular  layer  in  the  Malpighian  cor- 
puscles into  serous  cysts,  resulting  from  the  pressure  exerted  by  the 
Malpighian  corpuscles  when  tumefied  and  gorged  with  the  inflammatory 
product  of  these  diseases  upon  the  surrounding  strata.  The  latter  during 
their  metamorphosis  take  up  the  vessels  of  the  renal  coil  (Nierenknauel) 
for  the  purpose  of  the  new  secretions.  It  would  not  be  surprising  if 
their  contents  were  occasionally  urinous,  but  we  have  never  been  able  to 
discover  a  trace  of  urinous  precipitates  or  concretions  in  them.  We  have 
once  found  a  cyst  that  was  seated  at  the  circumference,  and  was  of  con- 
siderable size,  inflamed  and  ruptured,  and  its  contents  effused  into  the 
adipose  layer. 

£.  The  acephalocyst  is  a  morbid  product  that  occurs  in  the  kidney  ; 
less  frequently  certainly  than  in  the  liver,  but  more  frequently  than  in 
any  other  organ.  We  have  no  particular  remarks  to  offer  in  reference 
to  the  relations  of  this  variety  of  encysted  tumor,  to  its  contents,  or  to 
the  surrounding  tissues,  except  that  it  occasionally  reaches  the  extraordi- 
nary size  of  a  fist  or  a  child's  head,  and  that  it  may  discharge  its  con- 
tents in  various  directions.  The  following  modes  of  discharge  are  im- 
portant : 

aa.  Communication  of  the  cyst  with,  and  its  discharge  into,  the  colon 
(the  ascending  or  descending  colon),  and  consequent  evacuation  per 
anum,  and 

y5/9.  The  communication  of  the  cyst  with,  and  its  discharge  into,  the 
cavity  of  the  renal  pelves  and  calices.  Small  acephalocysts,  or  ruptured 
larger  ones,  may  thus  be  conveyed  by  the  ureters  to  the  bladder,  and  be 
evacuated,  as  is  particularly  the  case  with  females,  by  the  urethra  (mictus 
acephalocysticus),  or  they  induce  obstruction  and  dilatation  of  the 
urinary  passages  by  their  size. 

f.  The  composite  cystoidea  rarely  occur  in  the  kidneys  ;  though  when 
they  are  formed,  they  attain  a  considerable  size.  We  have  in  our  mu- 
seum an  illustrative  specimen,  in  the  left  kidney  of  a  boy  of  five  years 
of  age. 

c.  Anomalous ,  fibrous,  and  osseous  tissue. — We  find  fibroid  masses  of 
various  extent  and  shape  developed  in  the  products  left  by  inflammation 
and  Bright's  disease  ;  and  in  rare  cases  a  deposition  of  osseous  substance 
is  effected  within  them,  in  the  same  manner  as  we  find  occurring  in  the 
fibrous  exudations  of  serous  membranes.    The  calcareous  concretions  are 
not  however  in  this  case  laminse,  but  irregular  tuberculated  masses.   We 
also  find  that  a  fibrous  tissue  of  recent  formation  constitutes  the  external 
layer  of  the  acephalocysts  and  composite  cystoidea,  as  well  as  the  base 
and  fundamental  structure  of  cancerous  growths  in  the  kidneys. 

d.  Tubercle. — Tubercle  exists  in  the  kidneys  under  two  distinct  con- 
ditions ;  in  both,  however,  the  cortical  substance  is  the  chief  seat  of  the 
deposit. 

«.  In  one  case,  it  is  the  result  of  a  very  high  degree  of  tubercular 


THE     KIDNEYS.  161 

dyscrasia ;  a  partial  symptom  of  the  development  of  tubercular  disease 
in  many  or  the  majority  of  organs,  and,  in  that  case,  frequently  the  pro- 
duct of  a  very  tumultuous  process  of  deposition.  The  tubercles  are  found 
to  exist  in  great  numbers,  and  occur  in  the  shape  of  grayish-white,  deli- 
cate vesicular,  or  larger,  i.  e.  miliary  granulations,  surrounded  by  con- 
gested and  ecchymosed  parenchyma.  The  entire  viscus  is  swollen, 
gorged,  and  softened ;  it  is  hypersemie,  and  either  darker  than  ordinary, 
or  paler  and  infiltrated,  and  the  mucous  membrane  of  the  urinary  pas- 
sages is  reddened  and  injected.  If  the  morbid  process  takes  place  with 
less  intensity  and  has  a  more  chronic  duration,  the  tubercular  matter  is 
found  in  less  quantity,  of  the  size  of  millet-  or  hemp-seeds,  and  sur- 
rounded by  pale  tissue,  which  presents  no  trace  of  reaction  either  in  the 
vicinity  of  or  at  a  distance  from  the  tubercular  deposit. 

This  form  of  renal  tubercle  occurs  as  a  complication  of  tubercular  de- 
posit in  most  parenchymatous  organs  and  membranous  expansions ;  and 
especially  in  conjunction  with  tuberculosis  of  the  abdominal  viscera,  and 
more  particularly  of  the  spleen,  the  liver,  and  the  peritoneum.  Even 
when  occurring  under  violent  symptoms,  it  is  rarely  fatal  by  itself  by 
paralysis  of  the  renal  functions,  but  it  becomes  so  by  the  universal 
affection  and  by  the  coexistent  disease  of  other  organs.  This  variety  of 
renal  tubercle,  even  when  its  progress  is  less  rapid,  rarely  proceeds  fur- 
ther than  to  a  yellow  discoloration,  and  never  advances  to  actual  fusion. 
Both  kidneys  are  commonly  attacked  uniformly. 

/?.  In  the  other  case,  renal  tubercle  is  a  partial  appearance  of  tuber- 
cular disease  that  is  limited  to  the  male  urinary  and  sexual  organs.  It 
then  generally  attacks  the  testes  and  the  allied  lymphatic  and  prostate 
glands  primarily,  and  extends  from  these  to  the  urinary  apparatus,  i.  e. 
the  mucous  membrane  of  the  entire  tract,  to  the  kidneys,  and,  lastly,  to 
the  supra-renal  capsules.  It  is  commonly  viewed  as  possessing  a  blennor- 
rhoic  character  or  as  gonorrhoeal  tubercle ;  but  post-mortem  examina- 
tions have  not  established  the  fact  by  demonstrating  any  peculiarity  in 
the  tubercular  deposit.  It  very  often  supervenes  upon  a  previous  tuber- 
cular condition  of  the  lungs,  or  the  latter,  as  well  as  tubercle  in  other 
organs,  allies  itself  to  the  advanced  stage  of  renal  tubercle.  This  variety 
of  renal  tubercle  frequently  reaches  a  high  degree  as  regards  the  num- 
ber of  the  tubercles,  and  their  gradual  accumulation  into  extensive  groups 
and  coalition  into  large  masses.  The  viscus  is  found  to  have  increased 
in  size  and  is  nodulated,  and  the  tissues  in  the  vicinity  of  the  tubercle, 
or  throughout  the  organ,  are  in  a  state  of  chronic  reaction,  and  appear 
pale  and  dense,  and  infiltrated  with  lardaceous  matter,  and  the  tunica 
albuginea  is  thickened.  This  form  of  renal  tubercle  frequently  passes 
more  or  less  rapidly  into  the  stage  of  softening,  giving  rise  to  tubercular 
ulceration  (vomica  renis  tuberculosa),  tubercular  suppuration,  and  tuber- 
cular phthisis  of  the  kidneys. 

The  disease  generally  attacks  one  kidney  only  in  a  very  extensive 
degree. 

e.  Carcinoma. — Carcinomatous  growths  occur  frequently  in  the  kid- 
neys, and  in  the  primary  form.  This  is  particularly  the  case  with  me- 
dullary cancer,  which  we  find  attaining  a  very  large  size,  whereas  areolar 
and  hyaline  cancer  are  extremely  rare.  Of  these,  we  have  observed  the 

VOL.  II.  11 


ABNORMITIES  OF  THE  KIDNEYS. 

former  only  twice,  in  combination  with  medullary  cancer,  and  the  latter 
only  as  a  secondary  affection  accompanying  universal  cancerous  deposit. 

Medullary  cancer  appears  either  in  the  shape  of  more  or  less  numer- 
ous distinct,  rounded,  circumscribed  masses,  varying  in  size  from  that  of 
a  pea  to  that  of  a  walnut  and  a  hen's  egg,  of  dense  or  soft  texture  (en- 
cephaloid),  white  or  variously  colored  (melanotic) ;  these  circumstances 
generally  attend  the  rapid  development  of  universal  carcinomatous  de- 
position, and  therefore  indicate  secondary  cancer  of  the  kidney ;  as  a 
primary  affection,  it  appears  in  the  shape  of  a  carcinomatous  tumor,  ac- 
companied by  partial  infiltration  and  degeneration  of  the  adjoining 
tissues  ;  this  tumor  rapidly  increases  to  the  size  of  a  child's  or  adult's 
head,  forming  rounded  nodulated  masses,  which  perforate  the  fibrous 
sheath,  extend  to  the  peritoneum,  the  lymphatic  glands  of  the  lumbar 
plexus,  and  involve  the  periosteum  and  ligaments  of  the  abdominal  ver- 
tebrae ;  the  diseased  tissue  thus  becomes  fixed,  after  which  occurrence  it 
grows  into  the  cavity  of  the  renal  pelves  and  calices,  the  renal  veins  and 
the  vena  cava,  and  causes  their  obturation. 

The  latter  variety  generally  remains  the  focus  of  the  carcinomatous 
cachexia  and  the  sole  cancer  occurring  in  the  body,  on  account  of  its  ex- 
treme vegetative  power ;  yet  we  not  unfrequently  discover  in  its  vicinity 
and  especially  on  the  peritoneum,  the  diaphragmatic  pleura  of  the  dis- 
eased side,  and  in  the  liver,  isolated  cancerous  deposits. 

An  important  complication,  and  one  that  points  to  an  analogy  with 
tubercular  disease,  is  that  with  medullary  cancer  in  the  testicle  of  the 
same  side.  The  two  commonly  coexist,  or  the  renal  cancer  is  developed 
shortly  after  that  of  the  testis. 

We  have  noticed  the  disease  not  only  in  the  middle  period  of  life,  but 
both  in  advanced  age  and  in  early  youth  (as  early  as  in  the  fifth  year). 
Both  kidneys  appear  equally  liable  to  the  affection. 

When  the  growth  is  effected  with  great  violence,  hyperaemia  and  he- 
morrhage not  unfrequently  occur  in  medullary  carcinoma  of  the  kidney, 
and  when  it  extends  into  the  urinary  passages,  we  find  that  blood  is 
effused  into  them  also. 

6.  Anomalous  Contents. — Besides  the  anomalies  already  alluded  to, 
we  have  to  advert  to  the  following  morbid  contents  of  the  urinary  cana- 
liculi. 

a.  The  formation  of  calculous  urinary  concretions,  which  appear  in 
the  shape  of  delicate  granular  crystals,  dispersed  through  the  substance 
of  the  kidney,  and  which  consist  of  lithic  acid. 

b.  Entozoa ;  these  are,  besides  the  animalcules  inhabiting  the  acephalo- 
cyst,  the  cysticercus  and  the  very  rare  strongylus  gigas. 

§  8.  Special  disease  of  the  Investments  of  the  Kidneys. 

1.  Hy2^ertrophy  of  the  adipose  layer. — The  adipose  tissue  which  sur- 
rounds the  kidneys  may  increase  in  quantity  coincidently  with  a  universal 
increase  of  the  fat  of  the  body,  or  it  may  become  hypertrophied  by  itself; 
in  the  latter  case  it  may  increase  to  such  an  extent  as  to  force  its  way 
into  the  hilus  of  the  organ,  impede  its  nutrition,  and  cause  a  fatty  infil- 
tration of  the  kidney,  accompanied  by  anaemia  and  pallor.  It  appears 
that  rare  cases  of  this  description  have  been  occasionally  taken  for 
Bright's  disease,  and  this  has  given  rise  to  the  latter  being  thought  ana- 


DISEASES    OF    THE    URINARY    PASSAGES.  163 

logous  to  fatty  liver.  "When  it  has  advanced  to  the  highest  stage,  the 
kidney  presents  the  appearance  of  a  mere  piece  of  fat  surrounded  by  a 
mass  of  adipose  tissue,  and  without  the  slightest  traces  of  renal  organi- 
zation ;  the  urinary  passages  at  the  same  time  are  atrophied  and  obli- 
terated. 

Independently  of  universal  adipose  deposit,  we  find  a  larger  or  smaller 
excess  of  fat  enveloping  the  kidneys  of  old  people,  accompanied  by 
atrophy  of  the  organ ;  it  also  accumulates  when  the  kidney  is  affected 
by  moderate  but  lasting  inflammatory  irritation,  especially  that  caused 
by  calculi,  and  in  secondary  atrophy,  and  obliteration  of  the  kidney. 

2.  Per  {nephritis. — This  comprehends  inflammation  of  the  tunica  albu- 
ginea  and  of  the  fascia  adiposa  of  the  kidney.  It  results  from  wounds, 
concussion,  and  urinous  infiltration,  and  accompanies  both  the  inflamma- 
tion of  the  kidneys  and  that  of  the  pelves  and  calices. 

Inflammation  of  the  tunica  albuginea  is  characterized,  as  we  have  al- 
ready had  occasion  to  state,  by  development  of  the  vessels  of  the  cortical 
substance,  by  congestion  and  softening,  succulence  and  condensation  of 
its  tissue,  and  by  the  facility  with  which  it  may  be  detached.  It  is  always 
combined  with  inflammation  of  the  cortical  substance  of  the  kidney.  It 
is  only  when  the  latter  terminates  in  suppuration  that  the  disease  in  ques- 
tion has  a  similar  issue;  but  it  frequently  leaves  a  fibroid  thickening  of 
various  degrees,  combined  with  induration,  atrophy,  and  obliteration  of 
the  kidney,  resulting  from  inflammation  of  the  organ. 

Inflammation  of  the  fascia  adiposa,  which  is  particularly  apt  to  super- 
vene upon  the  tedious  inflammation  of  the  kidneys  and  their  pelves,  in- 
duced by  calculous  irritation,  has  the  general  characters  of  inflammation 
of  fatty  tissues  ;  it  induces  condensation  and  rusty  discoloration  ;  atrophy 
and  conversion  of  the  fat  into  a  white  or  slate-colored  cellulo-fibrous  tis- 
sue, which  forms  adhesions  with  the  thickened  albuginea  and  the  perito- 
neum ;  in  some  cases  suppuration  and  abscess  may  ensue. 

SECT.   II. — DISEASES   OF  THE   URINARY  PASSAGES. 

§  1.  Defect  and  Excess  of  Formation. — It  is  self-evident  that  where 
one  kidney  is  deficient,  the  corresponding  portion  of  the  urinary  passages 
must  be  entirely,  or  at  least  partially,  absent ;  but  when  the  kidneys  are 
present,  exceptional  cases  occur  in  which  the  ureters  terminate  in  a  cul- 
de-sac  in  the  vicinity  of  the  bladder,  and  also  in  the  neighborhood  of  the 
pelvis  of  the  kidney ;  or  we  may  find  in  addition  to  a  perfect  ureter,  a 
rudimentary  one  developed  at  the  bladder ;  or  finally,  the  apparatus  may 
have  undergone  an  arrest  of  development,  and  be  very  narrow,  and  have 
very  delicate  coats. 

If  the  kidneys  are  increased  in  number,  the  urinary  channels  are  also 
multiplied ;  but  more  frequently  the  apparent  excess  is  owing  to  fissure ; 
the  calices  opening  into  two  or  three  pelves,  which,  in  their  turn,  discharge 
themselves  into  two  or  three  ureters.  In  a  less  marked  degree  there  is  a 
single  pelvis,  which  is  divided  inferiorly  so  as  to  open  into  two  ureters  ; 
occasionally,  these  are  also  found  to  form  partial  subdivisions.  This 
malformation,  and  particularly  the  fissured  pelvis,  which  is  then  found 
partially  detached  from  the  organ,  frequently  accompanies  a  defective 


164  DISEASES    OF    THE 

development  of  the  hilus  of  the  kidney  ;  it  also  coexists  with  an  elongated 
state  and  a  transverse  division  of  the  kidneys. 

The  relation  of  the  vesical  orifice  of  the  fissured  ureters  to  the  bladder 
varies.  They  generally  coalesce  in  the  neighborhood  of  the  bladder,  or 
within  its  coats,  so  as  to  form  a  single  channel,  which  communicates  with 
the  cavity  of  the  bladder  by  a  single  mouth ;  they  rarely  open  by  sepa- 
rate orifices  placed  behind  one  another  at  one  side  of  the  trigonum 
Lieutaudi. 

When  the  kidney  occupies  an  irregularly  low  position,  the  length  of 
the  ureter  is  correspondingly  diminished. 

§  2.  Deviations  of  Calibre. — The  deviations  of  calibre  consist  in  dilata- 
tion of  the  urinary  passages,  caused  by  accumulations  of  urine,  which 
result  from  obstacles  to  its  discharge,  and  frequently  favored  by  an 
inflammatory  condition  of  the  mucous  membrane,  which  paralyzes  the 
external  contractile  layer.  It  will  depend  upon  the  position  of  the  im- 
pediment whether  the  dilatation  affects  a  larger  or  smaller  section  of  the 
apparatus.  If  the  former  occupies  the  vesical  orifice  of  the  ureter,  the 
entire  ureter,  the  pelvis,  and  lastly,  the  calices,  become  gradually  dilated ; 
it  is  evident,  as  we  shall  subsequently  examine  more  fully,  that  more  dis- 
tant impediments,  as,  for  instance,  those  placed  in  the  urethra,  must  also 
induce  dilatation. 

The  degree  in  which  the  dilatation  occurs  is  very  various ;  the  higher 
degrees  offer  on  their  own  account,  as  well  as  on  account  of  various  con- 
secutive anomalies,  numerous  points  of  interest.  Dilatation  of  the  pelves 
and  calices,  by  exerting  pressure  upon  the  renal  substance,  induces  atro- 
phy of  the  latter.  The  papilla  is  first  reduced ;  it  becomes  condensed 
and  coriaceous,  and  gradually  disappears  in  the  arch  of  the  expanded 
calyx ;  the  superimposed  renal  tissue  at  the  same  time  diminishing  in 
thickness,  becoming  denser,  and  assuming  a  leathery  toughness.  At  an 
advanced  stage  the  substance  of  the  kidney  may  be  only  one,  or  a  few 
lines  in  thickness,  and  even  disappear  altogether,  being  converted  into  a 
mere  membranous  sac  (hydrops  renalis,  Rayer's  hydronephrose),  with  an 
external  lobulated  appearance,  presenting  cells  within,  and  filled  with  a 
urinous,  variously  sedimentary  fluid,  or  with  clear  serum  ;  the  loculi  may 
intercommunicate  with  one  another,  in  consequence  of  atrophy  or  rupture 
of  the  contiguous  parietes.  These  sacs  sometimes  attain,  especially  in 
cases  which  are  unaccompanied  by  inflammation,  the  size  of  a  child's  or 
an  adult's  head ;  but  there  is  no  doubt  that,  after  the  urinary  secretion 
has  ceased,  in  consequence  of  atrophy  of  the  renal  tissue,  and  especially 
of  previous  inflammation,  they  may  be  reduced. 

Dilatation  of  the  ureters  exhibits  every  possible  degree ;  the  ureter 
may  even  attain  the  size  of  the  small  intestine.  It  is  then  found  hyper- 
trophied,  inasmuch  as  its  parietes  not  only  present  the  average  but  even 
increased  thickness  ;  and  as  it  is  increased  in  length,  and  consequently, 
instead  of  being  straight,  appears  coiled  or  bent.  At  the  same  time  the 
dilatation  is  not  uniform,  as  several  portions  of  the  ureter  are  narrower 
than  others,  the  external  cellulo-fibrous  tissue  accumulating  at  these 
points  during  the  dilatation,  and  offering  resistance.  To  this  fact,  also, 
is  owing  the  peculiar  direction  the  ureter  assumes,  as  the  curvature  or 


URINARY    PASSAGES.  165 

flexure  always  occurs  at  these  spots.  It  may  also  be  observed  that  the 
tube  rotates  upon  its  axis  at  these  points,  a  circumstance  which  further 
adds  to  the  diminution  of  its  calibre,  and  offers  a  new  obstacle.  The 
parietes  of  these  cavities  and  canals  always  bear,  as  we  ^have  already 
remarked,  that  proportion  to  the  dilatation,  that  they  must  be  considered 
hypertrophied  ;  they  only  attain  a  remarkable  and  extravagant  thickness, 
however,  if  there  is  concurrent  inflammation. 

The  following  circumstances  may  induce  the  occurrence  of  dilatation : 
Compression  of  the  ureter  at  different  points  by  morbid  growths,  by  the 
impregnated  uterus,  especially  by  cancer  of  the  womb  which  extends  to 
the  bladder,  by  fibroid  tumors  of  the  uterus,  by  enlarged,  and  particularly 
by  dropsical,  ovaries,  by  accumulation  of  urine  in  the  bladder  itself,  or 
by  lasting  contraction  of  the  bladder  consequent  upon  hypertrophy  of 
its  coats ; — contraction  of  the  ureter  from  tumefaction  of  its  coats,  con- 
sequent upon  inflammation  and  its  results ; — obliteration  of  the  ureter, 
and  obturation  of  the  calices,  the  pelvis,  and  ureter,  by  calculous  concre- 
tions ; — cancerous  growths  forcing  their  way  inwards  from  without ;  and, 
finally,  numerous  morbid  conditions  of  the  bladder,  the  prostate,  and  the 
urethra,  which  impede  the  discharge  of  the  urine  into  the  bladder,  or  the 
evacuation  of  the  latter. 

These  dilatations  are  consequently  generally  acquired  in  advanced  life, 
though  in  the  case  of  original  occlusion  (blind  termination)  of  the  urinary 
passages,  they  may  be  congenital. 

In  a  particular  case  that  we  have  observed,  the  pressure  exerted  by 
an  irregular  branch  of  the  emulgent  artery,  of  one  line  in  diameter,  that 
descended  from  the  upper  end  of  the  hilus,  so  as  to  form  an  arch  over 
the  convoluted  transition  of  the  pelvis  to  the  ureter  on  the  right  side, 
caused  a  dilatation  of  the  former. 

The  contractions  of  the  urinary  passages  are  sufficiently  explained  in 
the  above ;  they  are  also  the  result  of  renal  atrophy,  and  may  amount  to 
complete  obliteration  and  closure  of  their  calibre. 

§  3.  Anomalies  of  Position. — As  a  congenital  anomaly,  we  mention 
the  detached  position  of  the  single  or  multiplied  pelvis  of  the  kidney  ac- 
companying an  imperfectly  developed  state  of  the  renal  labia,  and 
especially  occurring  in  cases  of  anomalous  formation  and  position  of  the 
kidney :  acquired  anomalies  of  position  are  brought  on  by  pressure 
exerted  upon  the  ureter  by  irregularities  of  the  neighboring  organs. 

§  4.  Anomalies  of  Texture. — 1.  Inflammation  of  the  urinary  passages 
have  to  be  first  mentioned,  and  especially — 

a.  Catarrhal  inflammation,  both  on  account  of  its  frequent  occurrence, 
as  on  account  of  its  consequences  and  its  transition  to  the  substance  of 
the  kidneys.  As  a  primary  disease,  it  appears  in  the  shape  of  inflam- 
mation of  the  renal  pelvis  and  the  calices  (pyelitis),  with  inflammation 
of  the  kidney,  as  may  be  gathered  from  the  description  of  nephritis  and 
Bright' s  disease ;  it  may  be  secondary,  owing  to  irritation  exerted  by 
accumulation  of  urine  and  urinary  concretions  on  the  mucous  membrane 
of  these  parts  (pyelitis  calculosa) ;  and  it  may  also  be  and  very  often  is 
metastatic,  the  inflammation  of  the  bladder  being  transferred  to  the 
ureters,  the  pelves,  and  calices. 


166  DISEASES    OF    THE 

It  is  either  acute,  as  in  the  case  of  complication  with  acute  nephritis, 
or  more  commonly  chronic,  being  maintained  by  lasting  and  repeated 
noxious  influences,  or  being  the  result  of  a  chronic  morbid  process  in  the 
bladder,  in  which  case  we  meet  with  temporary  acute  exacerbations.  It 
is  of  extreme  importance,  and  renders  the  following  details  necessary. 

The  characters  are,  in  proportion  to  the  degree  of  intensity  and  dura- 
tion, a  dusky  reddish  or  brown-red  congestive  state,  similar  or  ashy  dis- 
colorations  in  the  shape  of  solitary  spots  or  islands,  or  of  extensive  con- 
nected patches,  tumefaction  and  villosity  of  the  mucous  membrane,  and 
secretion  of  a  yellow  puriform  mucus,  blennorrhoea. 

The  longer  the  inflammatory  condition  lasts,  the  more  the  gradual  di- 
latation of  the  urinary  passages,  with  hypertrophy  of  the  membranes, 
increases,  both  in  consequence  of  the  paralysis  of  the  external  contractile 
and  irritable  layer  as  from  the  accumulation  of  the  renal  and  the  morbid 
mucous  secretion. 

At  an  advanced  degree,  as  in  the  temporary  exacerbation  of  chronic 
inflammation,  the  mucous  membrane,  particularly  when  subject  to  irrita- 
tion by  gravel  and  calculi,  which  chiefly  affect  the  calices  and  pelves, 
appears  of  a  saturated  red  color,  considerably  swollen,  spongy,  and 
friable  ;  a  purulent,  more  or  less  sanguineous,  fluid  is  secreted  (superficial 
suppuration),  the  surrounding  cellular  and  adipose  tissues  are  traversed 
by  varicose  vessels,  and  infiltrated.  We  find  that  moderate  catarrhal 
inflammation  of  the  ureters  gradually  extends  to  the  kidney  in  the  shape 
of  chronic  inflammation  ;  it  equally  attacks  the  kidney  with  tumultuous 
symptoms  as  acute  inflammation  when  it  has  reached  this  advanced  degree, 
and  thus  proves  fatal. 

The  above-mentioned  high  degree  of  inflammation  is  also  found  to  pass 
into  suppuration  of  the  urinary  passages,  which  spreads  from  the  calices 
to  the  tissue  of  the  kidneys,  and  causes  in  the  latter  the  formation  of 
abscesses  or  extensive  ulcerative  destruction,  occasionally  urinous  infiltra- 
tion of  the  renal  parenchyma,  gangrenous  ulceration,  and  gangrene  of 
the  calices  and  pelvis.  We  thus  find  it  gradually  proceeding  in  the 
ureters  to  perforation,  slow  infiltration  of  urine  in  the  adjoining  tissues, 
inflammation,  suppuration,  necrosis,  and  in  fortunate  cases,  formation  of 
circumscribed  abscesses  with  indurated  parietes. 

In  these  various  conditions,  the  urinary  passages  contain  an  alkaline 
urinous  fluid  of  a  pungent  odor,  which  is  variously  discolored ;  it  is  mixed 
up  with  puriform  mucus  or  true  pus,  sanies,  blood,  and  portions  of  broken- 
up  tissue,  and  it  frequently  deposits  a  sedimentary  incrustation  upon  the 
inflamed  mucous  membrane. 

In  rare  cases  the  advanced  stages  of  the  disease  terminate  favorably 
in  obliteration  of  the  urinary  passages.  After  the  cessation  of  the  urinary 
secretion,  consequent  upon  complete  atrophy  of  the  renal  tissue,  from 
pressure  exerted  by  the  dilated  renal  calices,  or  more  frequently  conse- 
quent upon  the  coexisting  chronic  inflammation  of  the  kidney,  the  tissues 
contract,  the  parietes  become  thickened,  and  the  calibre  of  the  passages 
is  gradually  reduced,  till  complete  obliteration  results.  The  fluid  con- 
tained in  the  cavity  of  the  calices,  which  consists  of  blennorrhoic  mucus, 
pus,  and  urine,  the  latter  being  strongly  impregnated  with  alkalies,  salts 
of  lime,  and  particularly  with  phosphates,  first  causes  an  incrustation  on 


URINARY    PASSAGES.  167 

the  parietes  of  the  calices,  and  then  becomes  inspissated,  so  as  to  form  a 
grayish  or  yellowish-white,  greasy,  and  chalky  pulp,  which  fills  the  ca- 
lices ;  the  kidney  thus  presents  the  appearance  of  a  loculated  cyst,  the 
compartments  of  which  contain  the  pulp,  and  radiate  from  the  hilus  to 
the  circumference.  This  pultaceous  substance  is  in  due  course  converted 
into  a  dry  mortar-like,  gritty,  dense,  calculous  mass,  and  the  tissues  con- 
tracting at  the  same  time,  the  sac  is  reduced,  the  kidney  and  the  efferent 
channels  are  obliterated.  Occasionally  this  metamorphosis  is  observed 
to  take  place  in  one  or  more  detached  calices. 

Occasionally  laminated,  corded,  nodulated,  and  amorphous  bony  con- 
cretions are  formed  in  the  membranes  of  the  renal  calices  and  pelves, 
after  these  have  been  previously  converted  into  a  fibroid  or  cartilaginous 
tissue  by  the  inflammatory  process ;  the  same  may  occur  in  the  ureter, 
though  we  have  not  observed  it  ourselves. 

b.  Exudative  inflammation. — This  is  on  the  whole  an  unusual  occur- 
rence, and  as  far  as  we  are  able  to  judge,  invariably  a  secondary  affection ; 
we  have  never  met  with  a  case  of  idiopathic  croup  of  the  urinary  organs. 
It  is  found  complicated  with  products  of  the  most  various  plasticity,  fol- 
lowing typhus,  exanthematic  diseases,  more  especially  variola  and  scarla- 
tina, exudative  processes  in  other  tissues,  as  diphtheritis  and  acute  tuber- 
culosis, and  purulent  infection  of  the  blood ;  it  is  very  frequently  the 
consequence  of  extreme  disorganization  of  the  blood  (especially  the  so- 
called  status  putridus),  and  then  appears  as  hemorrhagic  exudation  with 
purple  or  dark-red  discoloration,  sanguineous  infiltration,  friability  and 
solution  of  the  mucous  tissue,  and  hemorrhage.  It  may  extend  over  a 
large  surface,  or  be  confined  to  isolated  spots,  and  it  not  unfrequently 
implies  gangrene. 

2.  Morbid  growths. — a.  Fibroid  tissue  and  calcareous  concretions  re- 
sult from  chronic  inflammation  of  the  urinary  passages  in  the  manner 
above  described. 

b.  Cysts  appear  to  be  more  frequent  in  the  urinary  passages  than  they 
are  in  and  upon  other  excretory  ducts.     Without  referring  to  older  cases, 
we  may  notice  two  that  have  been  observed  in  the  Vienna  Hospital. 
They  represent  cysts  of  the  size  of  millet-seeds  or  peas,  developed  under 
the  mucous  membrane,  and  either  grouped  together  or  solitary,  contain- 
ing a  colorless  or  yellowish  serous  fluid,  in  which  is  found  a  soft  glutinous 
or  hard  nodule,  varying  in  size,  and  resembling  amber  or  horn ;  these 
cysts  and  the  mucous  covering  occasionally  burst,  which  is  proved  by 
the  concretions  having  been  discovered  unattached  in  the  bladder.  They 
were  found  chiefly  occupying  the  ureters,  and  in  one  case  the  pelves  and 
calices  of  the  kidneys. 

c.  Tubercle. — This  occurs  as  tubercular  affection  of  the  mucous  mem- 
brane, and  is  always  a  symptom  of  tubercular  disease  that  has  spread 
from  the  male  genitals  to  the  urinary  organs.     The  earlier  stages  and 
the  chronic  course  of  the  disease  are  marked  by  gray  millet-sized  granu- 
lations in  the  submucous  cellular  tissue,  which  speedily  become  yellow, 
soften,  and  after  perforating  the  mucous  membrane  within  a  ring  of  re- 
active inflammation,  give  rise  to  small  circular  ulcers,  which  but  rarely 
enlarge  to  the  dimensions  of  a  pea  or  a  bean.     When  the  disease  sets  in 
with  great  violence,  the  mucous  membrane  is  attacked  in  larger  sinuous 


168  ABNORMITIES    OF    THE 

or  annular  patches,  or  becomes  infiltrated  throughout  with  the  tubercular 
product  of  inflammation,  which  is  at  once  detached  as  a  cheesy  purulent 
mass.  The  mucous  membrane  is,  under  these  circumstances,  converted 
into  a  thick,  yellow,  fissured,  and  purulent  layer,  the  external  cellulo- 
fibrous  layer  of  which  presents  a  lardaceous  character ;  the  calibre  of 
the  canal  is  enlarged.  At  those  parts  which  are  not  affected  by  this 
degeneration,  we  not  unfrequently  find  numerous  aphthous  erosions,  re- 
sembling those  observed  in  pulmonary  and  laryngeal  phthisis. 

Tubercular  suppuration  occasionally  passes  from  the  pelvis  of  the  kid- 
ney to  its  parenchyma,  and  it  here  not  unfrequently  meets  with  soften- 
ing tubercles,  or  even  with  tubercular  abscesses. 

d.  Cancer. — Cancer  occurs  very  rarely  as  a  primary  disease  of  the 
mucous  membrane  of  the  urinary  passages,  and  never  except  in  company 
with  one  or  several  cancerous  formations  in  other  organs  already  in  a 
process  of  development ;  in  these  cases  it  affects  the  calices  and  pelvis 
of  the  kidney,  and  chiefly  assumes  the  medullary  or  fungoid  form. 

The  parietes  of  the  urinary  passages  are  very  often  involved  in  a  secon- 
dary degeneration  by  the  encroachment  of  cancerous  growths  from  with- 
out ;  the  calices  and  pelvis  being  attacked  by  carcinoma  of  the  kidney, 
the  ureters  by  cancer  of  the  uterus.  Their  cavities  are  narrowed  by  the 
cancerous  products,  and  even  entirely  closed  up. 

SECT.   III. — ABNORMITIES   OF   THE   URINARY  BLADDER. 

§  1.  Defect  and  ^Excess  of  Formation. — Arrest  of  development  occurs 
in  various  forms  and  degrees. 

Complete  defect  is  a  very  rare  occurrence ;  we  may  meet  with  it  accom- 
panying a  very  imperfect  development  of  the  kidneys,  with  absence  of 
the  urethra,  and  commonly  also  as  a  complication  of  formative  defects 
of  other  organs.  If,  under  these  circumstances,  the  ureters  are  well 
formed,  they  open  at  the  navel,  into  the  rectum,  or  the  vulva. 

Occasionally  the  bladder  is  very  small,  whilst  the  other  portions  of 
the  urinary  apparatus  are  of  normal  size  ;  its  parietes  are  then  imper- 
fect ;  it  is,  in  fact,  represented  by  a  delicate  mucous  bag,  a  mere  dilata- 
tion of  the  ureters. 

The  various  fissures  of  the  bladder  are  other  forms  of  arrest  of  deve- 
lopment. We  allude,  first  to  the  very  rare  cases  of  fissure  or  division  of 
the  bladder  by  means  of  a  perfect  or  an  imperfect  partition  in  the  median 
line,  the  so-called  double  bladder.  That  variety  of  this  species  of  defect 
is  much  more  frequent,  which  has  been  termed,  from  its  appearance, 
ectrophia  or  inversion  of  the  bladder.  It  is  the  result  of  a  fissure,  or  a 
defect  of  the  anterior  vesical  parietes,  and  is  not  unfrequently  associated 
with  fissures  of  adjoining  viscera  in  the  mesian  line.  It  is  more  parti- 
cularly accompanied  by  a  defect  of  the  symphysis  pubis — in  the  female 
sex  by  absence  of  the  anterior  commissure  of  the  labia  and  the  clitoris ; 
in  the  male  sex,  by  fissure  of  the  urethra  on  the  dorsal  surface  of  the 
penis,  or  epispadiasis.  In  the  case  of  inversion  of  the  bladder,  we  find  in 
the  hypogastrium,  immediately  beneath  the  navel,  which  is  always  placed 
very  low,  a  red,  mucous,  dilated  spot,  the  edges  of  which  coalesce  with 
the  common  integument :  in  the  male  sex  it  passes  downwards,  so  as  to 


URINARY    BLADDER.  169 

terminate  in  the  fissure  of  the  urethra ;  in  the  female  it  is  surrounded 
by  two  diverging  tumors  which  represent  the  labia,  and  it  terminates  in 
the  lamina  of  the  general  integument  which  invests  the  rima  vulvae.  The 
ureters  open  upon  this  mucous  surface,  and  their  orifice  is  generally  found 
at  the  inferior  half. 

The  exposed  vesical  mucous  membrane  and,  owing  to  the  constant  stilli- 
cidium  of  urine  from  the  ureters,  the  neighboring  cutaneous  surface, 
become  irritated,  reddened,  and  excoriated.  In  a  very  old  preparation 
taken  from  an  adult,  which  has  been  transferred  from  the  Anatomical 
Museum  of  the  University  to  the  Pathological  Collection,  I  find  the  former 
in  a  state  of  fungoid  degeneration. 

When  the  fissure  of  the  urinary  bladder  occurs  in  an  opposite  direc- 
tion, and  is  accompanied  by  fissure  of  the  genital  cavities  and  the  rectum, 
we  obtain  the  formation  of  cloacae  in  their  various  degrees.  The  urachus 
may  remain  patent  to  a  certain  distance  from  the  bladder,  or  throughout 
its  entire  extent. 

We  have  also  to  allude  to  defective  development  occurring  in  the  shape 
of  unusual  contraction  of  the  vesical  orifice,  or  atresia  vesicse. 

In  biventral  monsters,  the  bladder  is  found  more  or  less  competely 
double. 

§  2.  Deviations  of  Size  and  Form.  Hypertrophy  and  atrophy  of  the 
bladder. — With  the  exception  of  the  above-mentioned  congenital  small- 
ness  of  the  bladder,  and  the  congenital  dilatations  of  the  organ  from 
contraction  or  atresia  of  the  urethra,  the  anomalies  to  be  classed  under 
this  head  are  all  acquired ;  they  are  the  conditions  of  permanent  and 
excessive  dilatation  and  contraction. 

Dilatation  of  the  bladder  is  seen  under  various  forms.  It  may  be 
uniform  and  general,  and  in  solitary  cases  attains  such  an  extent,  that 
the  bladder  is  represented  by  a  fluctuating  paralyzed  sac,  with  relatively 
thickened  parietes,  filling  the  entire  pelvis  and  hypogastric  region.  It 
is  caused  by  accumulation  of  urine,  consequent  upon  insensibility  and 
paralysis  of  the  bladder,  but  more  particularly  by  mechanical  obstacles 
in  the  neck  of  the  bladder  and  in  the  urethra ;  in  the  last  case  espe- 
cially, that  extreme  degree  is  developed  which  is  always  accompanied  by 
hypertrophy  of  the  parietes. 

Dilatation  of  the  ureters  is  a  consequence  of  this  affection ;  it  proves 
fatal  by  inflammation  resulting  from  the  influence  of  the  stagnating  and 
decomposed  urine  upon  the  mucous  membrane,  by  the  consequent  suppu- 
ration and  gangrene,  and  especially  by  peritonitis. 

Dilatation  occasionally  affects  in  a  greater  or  less  degree  certain  por- 
tions, or  predominates  in  certain  directions  ;  thus  we  find  lateral  expan- 
sions at  the  fundus  vesicae,  and  saccular  indentations  produced  by  the 
pressure  of  calculi  at  or  posterior  to  the  triangle  of  Lieutaud. 

An  important  variety  of  partial  vesical  dilatation  is  presented  to  us  in 
the  hernial  dilatation,  or  acquired  diverticulum  of  the  bladder.  It  is 
always  developed  in  a  bladder  the  muscular  coat  of  which  is  hypertro- 
phied,  and  this  hypertrophy,  being  accompanied  by  increased  irritability 
of  the  bladder,  affords  an  evident  and  intelligible  explanation  for  the  pre- 
disposition. The  vesical  mucous  membrane  insinuates  itself  between  the 


170  ABNORMITIES    OF    THE 

fissures  left  by  the  rounded  or  hypertrophied  fleshy  columns,  is  gradually 
forced  through  them,  and  forms  saccular  appendages  to  the  bladder, 
which  increase  by  degrees,  and  attain  a  size  varying  from  that  of  a  wal- 
nut or  hen's  egg  to  that  of  a  fist  or  a  human  head.  Their  cavity  at  first 
communicates  with  the  bladder  by  means  of  an  elongated  rhomboidal 
opening,  and  the  more  they  increase,  the  more  the  latter,  being  enlarged 
at  the  same  time,  is  converted  into  a  round  sphincter. 

These  diverticula  occur  principally  at  the  lateral  portions  and  near  the 
vertex  of  the  bladder;  they  are  also  found  at  the  posterior  surface, 
and  may  frequently  be  seen  at  all  these  points  at  once.  The  diverti- 
culum  is  very  rarely  developed  in  the  triangle  near  the  perineum.  Its 
parietes  are  formed  of  the  mucous  membrane  of  the  bladder,  which, 
under  certain  self-evident  circumstances,  is  invested  by  the  peritoneum. 
Sometimes  a  few  muscular  fibres  traverse  the  diverticulum,  which  circum- 
stance may  cause  it  to  be  viewed  as  congenital. 

If  there  happens  to  be  concurrent  calculous  disease  of  the  bladder, 
the  diverticula  acquire  additional  importance,  as  the  calculi  may  pass 
into  them,  or  be  formed  within  their  cavity,  and  either  be  firmly  grasped 
or  float  unattached.  The  mucous  membrane  of  small  diverticula  is  fre- 
quently the  seat  of  chronic  inflammation,  causing  a  muco-purulent  secre- 
tion, and  followed  by  ulcerative  perforation  and  the  formation  of  sinuses 
between  the  vesical  coats ;  these  sinuses  traverse  the  trabecular  struc- 
ture of  the  muscular  coat  in  the  most  various  directions. 

Permanent  contraction  of  the  bladder  occurs  in  various  degrees  as  a 
consequence  of  enduring  irritation,  e.  g.  by  a  calculus  ;  or  of  increased 
irritability  of  the  mucous  membrane  from  inflammation.  The  longer 
these  influences  last,  the  more  the  parietes  increase  in  thickness  and 
hardness,  so  that  they  not  unfrequently  present  the  appearance  of  a  ball 
contracted  to  the  size  of  a  duck's  or  hen's  egg. 

The  contraction  is  at  times  partial,  and  may  then  give  rise  to  a  per- 
manent coarctation  of  the  bladder  at  one  or  even  at  several  points.  The 
bilocular  vesicae,  noticed  by  ancient  anatomists,  probably  took  their 
origin  in  a  morbid  contraction  of  this  nature. 

As  regards  the  diameter  of  the  vesical  parietes,  we  pass  over  nume- 
rous morbid  conditions  which  give  rise  to  thickening,  and  which  will  be 
investigated  subsequently,  and  have  now  to  examine  the  states  of  hyper- 
trophy and  atrophy. 

Both  are  most  apparent  in  the  muscular  coat ;  hypertrophy  of  the 
mucous  membrane  is  chiefly  seen  in  connection  with  chronic  congestion 
and  catarrh  of  the  bladder,  and  we  shall  examine  into  it  more  fully  in 
speaking  of  these  affections. 

Hypertrophy  of  the  muscular  coat  takes  place  in  consequence  of 
catarrhal  affections  of  the  vesical  mucous  membrane ;  of  repeated  and 
enduring  irritation,  especially  from  urinary  concretions  ;  of  excessive 
efforts  made  to  overcome  obstacles  to  the  discharge  of  the  urine.  The 
latter  may  affect  either  the  neck  of  the  bladder  or  the  urethra,  and  be 
caused  by  the  pressure  exerted  upon  these  parts  by  enlarged  or  dislo- 
cated organs  in  the  vicinity ;  as  by  prolapsus,  tumors,  and  degenerations 
of  the  uterus,  uterine,  vaginal,  and  rectal  cancer,  by  the  enlarged  pro- 
state, strictures  of  the  urethra,  &c.  The  muscular  fasciculi  are  found 


URINARY    BLADDER.  171 

thickened,  so  as  to  form  rounded  trabeculae,  which  project  from  the 
inner  surface  of  the  bladder  in  the  shape  of  a  trabecular  network,  com- 
parable to  the  inner  surface  of  the  right  ventricle  of  the  heart  (vessie  a 
colonne],  the  mucous  membrane  insinuates  itself  within  its  meshes,  unless, 
the  bladder  ^be  permanently  contracted,  and  finally  forces  its  way 
through  them  in  the  shape  of  diverticula. 

The  bladder  is  at  the  same  time  either  dilated,  or  if  the  irritability  of 
the  mucous  membrane  is  increased,  it  is  contracted.  In  the  latter  case 
especially,  the  entrance  of  the  urine  from  the  ureters  is  variously  im- 
peded, and  thus  a  dilatation  of  the  urinary  passages  ensues. 

We  must,  however,  be  cautious  not  to  mistake  a  bladder  with  thick 
walls,  which  is  perfectly  contracted  after  it  has  been  completely  emptied, 
for  a  case  of  hypertrophy. 

Atrophy  of  the  vesical  parietes  occurs  rarely.  The  mucous  membrane 
may  be  reduced  to  a  very  delicate,  shining  membrane,  resembling  the 
arachnoid,  and  the  muscular  coat  disappears,  with  the  exception  of  a  few 
almost  imperceptible  pale  traces ;  the  contractile  power  of  the  bladder 
ceases,  its  parietes  are  in  a  state  of  permanent  relaxation,  soft,  thin, 
transparent,  pale,  anaemic,  and  friable.  We  have  twice  observed  atrophy 
of  the  vesical  parietes  of  this  description  as  a  substantive  disease. 

The  shape  of  the  bladder  is  liable  to  numerous  deviations.  All  the 
congenital  malformations  that  are  connected  with  the  above-mentioned 
anomalies  of  development  belong  to  this  head,  and  as  acquired  malfor- 
mations, we  may  mention  those  accompanying  dilatation,  especially 
when  effected  in  one  direction,  and  causing  diverticula,  those  resulting 
from  irregular  and  constant  contraction,  and  those  assuming  the  cylin- 
drical, cuneiform,  or  cordate  form,  in  consequence  of  hypertrophic  con- 
ditions. 

§  3.  Anomalies  of  Position. — These  involve  the  dislocation  of  the 
bladder  from  its  normal  position,  and  in  various  directions,  by  enlarged 
neighboring  viscera,  and  voluminous  morbid  growths  in  the  pelvic  cavity, 
by  contraction  and  malformation  (especially  that  resulting  from  mollities 
ossium)  of  the  pelvis ;  the  dragging  down  of  the  bladder  by  dislocated 
viscera  in  its  vicinity,  especially  by  the  prolapsed  uterus,  and  by  large 
morbid  growths  in  the  perineum,  the  position  occupied  by  the  bladder 
in  large  inguinal,  perineal,  and  vaginal  hernise  ;  the  intussusception  of  the 
bladder  in  the  urethra,  and  its  prolapsus  through  the  latter  in  females  ; 
the  eversion  of  the  bladder  in  consequence  of  a  rupture  affecting  both  it 
and  the  vagina. 

§  4.  Solutions  of  Continuity. — We  class  under  this  head — 

1.  Injuries  of  the  bladder  by  means  of  cutting  instruments,  including 
the  surgical  wounds  caused  by  cystotomy  and  puncture  of  the  bladder ; 
the  contusions  produced  by  the  head  of  the  child  during  parturition,  by 
obstetric  instruments,  by  splinters  of  bone  arising  from  pelvic  fractures, 
or  by  concussion  received  by  a  fall  or  a  blow  ;  rupture  of  the  bladder  ac- 
companied by  more  or  less  diffused  infiltration  of  the  vesical  membranes 
and  the  surrounding  cellular  tissue,  and  hemorrhage. 

2.  The  very  rare  spontaneous  ruptures  of  the  bladder  resulting  from 
excessive  repletion  and  distension  of  the  latter. 


172  ABNOKMITIES    OF    THE 

In  both  cases  the  termination  may  vary ;  in  favorable  circumstances  a 
cure  may  result ;  extravasation  of  urine  into  the  peritoneal  cavity  and 
peritonitis,  or  urinous  infiltration  of  the  cellular  tissue,  with  diffuse  in- 
flammation, suppuration,  gangrene,  and  under  these  circumstances  com- 
monly a  fatal  issue,  may  take  place  ;  or  if  the  secondary  processes  are 
circumscribed,  abnormal  openings  may  be  established,  and  vesical  fistulas 
form. 

3.  The  ulcerative  solutions  of  continuity  occurring  from  within  as 
well  as  from  without,  together  with  the  consequent  and  frequent  con- 
stricted or  patulous  communications  between  the  bladder  and  neigh- 
boring cavities  and  channels,  the  intestinal  tube,  and  particularly  the 
rectum,  the  uterine  and  vaginal  cavities,  abscesses,  &c. 

§  5.  Anomalies  of  Texture. — Here  too  the  diseases  of  the  mucous 
membrane  are  of  main  interest,  as  those  of  the  muscular  coat  are  rare  in 
themselves,  and  when  they  occur  are  generally  consecutive  or  secondary. 
We  shall  consider  them  in  their  proper  places. 

1.  Hypercemia  of  the  Bladder. — Besides  the  congestion  existing  as  a 
stage  preparatory  to  and  associated  with  inflammation,  we  find  hyper- 
aemia  occurring  not  unfrequently  as  a  result  of  mechanical  impediments 
to  the  circulation  in  the  pelvic  veins  and  the  vena  cava.     It  is  commonly 
complicated  with  hyperaemia  of  the  neighboring  pelvic  viscera,  of  the 
rectum,  the  uterus,  and  the  vagina  ;  it  gives  rise  to  a  more  copious  secre- 
tion of  mucus  in  the  bladder,  to  hypertrophy  of  the  mucous  membrane^ 
and  is  followed  by  a  permanent  dilatation  of  the  vessels,  and  habitual 
congestion.     The  condition  accompanying  stases  in  the  hemorrhoidal 
vessels  of  the  rectum,  in  the  shape  of  vesical  hemorrhoids,  is  one  of  this 
nature. 

Extravasation  or  apoplexy  of  the  vesical  membranes,  and  hemorrhage 
into  the  cavity  of  the  bladder,  as  a  consequence  of  hypersemia,  is  a  very 
rare  occurrence.  Even  in  those  rare  cases  it  is  always  limited  to  a  few 
small  spots,  and  they  must  be  carefully  distinguished  from  the  dark-red 
suffusions  of  the  vesical  mucous  membrane,  into  which  the  hypersemic 
condition  which  is  followed  by  secondary  exudative  processes  and  gan- 
grene frequently  degenerates. 

2.  Inflammation,    a.   Catarrhal  inflammation. — This  occurs  in  the 
acute  form,  but  more  frequently  as  a  chronic  affection ;  it  is  commonly 
presented  to  the  morbid  anatomist  in  the  latter  shape. 

Both  generally  offer  the  symptoms  common  to  catarrhal  inflammations. 
Relatively  to  the  chronic  form,  we  have  the  following  observations  to 
make: 

It  may  be  developed  gradually  in  consequence  of  repeated  attacks  of 
acute  inflammation,  or  be  left  as  a  residuary  affection  after  the  incom- 
plete cure  of  the  latter ;  or,  as  is  very  frequently  the  case,  catarrhal  in- 
flammation results  from  an  extension  of  gonorrhoeal  catarrh  to  the 
bladder.  It  may  also  be  induced  by  the  continued  irritation  of  long- 
retained  and  decomposed  urine,  as  is  the  case  when  the  discharge  of  the 
urine  is  impeded ;  or  lastly,  by  the  irritation  arising  from  calculi. 

It  offers  various  degrees  ;  from  a  pale  circumscribed  redness,  occa- 
sionally surrounding  the  crypts  only,  slight  opacity  and  thickening, 


URINARY    BLADDER.  173 

increase  of  villosity  and  secretion  of  a  grayish-white  liquid  mucus,  to  a 
dark  reddish-brown,  slaty  or  bluish-black  discoloration,  accompanied  by 
considerable  spongy  tumefaction,  and  the  secretion  of  mucus,  which  is 
partly  vitreous  and  clotted,  partly  yellow  and  puriform  (blennorrhoea). 
The  longer  the  disease  lasts,  the  more  the  mucous  membrane,  from  its 
increased  irritability  and  from  the  permanently  increased  innervation  of 
the  muscular  coat,  becomes  hypertrophied ;  the  cavity  of  the  bladder  is 
diminished  in  consequence,  and  if  this  condition  attains  a  certain  point, 
paralysis  of  the  muscular  fibres  and  consequent  dilatation  of  the  bladder 
ensue. 

In  this  secondary  condition,  after  the  affection  has  lasted  a  considera- 
ble period,  a  rapid  exacerbation  of  the  chronic  catarrh  is  frequently 
brought  on  by  the  irritation  exerted  upon  the  vesical  mucous  membrane 
by  the  accumulation  of  decomposed  alkaline  urine.  The  inflammation 
speedily  attains  a  high  degree,  and  terminates  in  exudation,  fusion  of  the 
mucous  tissue,  suppuration,  and  gangrene. 

Under  these  circumstances  the  bladder  is  found  dilated,  and  filled  with 
decomposed,  intensely  alkaline  urine,  mixed  up  with  blood  of  a  brown 
color,  viscid  mucus  and  pus,  sanies,  lymph,  and  detached  portions  of  mu- 
cous tissue  in  the  shape  of  discolored  flocculi  or  larger  patches.  From 
this  liquid,  which  offers  a  pungent  ammoniacal  odor,  a  soft,  pulverulent, 
mealy  sediment,  consisting  of  calculous  matter  bound  together  by  lym- 
phatic exudation,  is  deposited  upon  the  internal  surface  of  the  bladder. 
The  parts  themselves  are  discolored,  and  present  a  dark  reddish-brown, 
greenish-gray,  or  bluish-black  hue.  The  mucous  membrane,  when  pre- 
senting a  dark-red  color,  appears  spongy,  softened,  and  pultaceous,  is 
easily  detached  and  bleeds ;  when  chocolate-colored  or  greenish  it  is 
found  purulent,  infiltrated  with  sanious  matter,  or  converted  into  a 
friable  flocculent  tissue,  which  is  traversed  by  the  urinary  sediment ;  or 
if  the  process  of  solution  is  completed,  and  the  mucous  membrane  has 
become  detached,  the  surface  of  the  cellular  and  muscular  coats  is  ex- 
posed in  larger  or  smaller  sinuous  patches,  appears  frayed  and  pulpy,  in- 
filtrated with  purulent  sanies,  discolored,  softened,  and  friable.  Finally, 
the  muscular  coat  is  involved  in  the  suppurative  and  gangrenous  destruc- 
tion, and  general  peritonitis  ensues ;  or  even  before  this  takes  place 
sinuses  are  formed  between  the  vesical  membranes,  the  parietes  of  the 
bladder  are  eaten  through,  and  present  a  cribriform  appearance,  and  the 
urine  exudes  into  the  surrounding  cellular  tissue  and  into  the  peritoneal 
cavity.  The  bladder  is  converted  into  a  paralyzed  sac,  the  coats  of 
which  are  thickened,  though  they  yield  on  slight  pressure,  they  are  dis- 
colored, and  infiltrated  with  pus  and  sanies. 

The  disease  commonly  proves  fatal,  either  directly  or  by  extension  of 
inflammation  to  the  ureters  and  kidneys. 

In  other  cases  the  disease  has  slight  exacerbations  from  time  to  time, 
being  limited  to  a  more  or  less  circumscribed  spot,  which  undergoes  a 
slower  process  of  suppuration,  and  at  last  becomes  perforated.  If,  under 
such  circumstances,  the  tissues  external  to  the  bladder  have  become  the 
seat  of  inflammatory  action  previous  to  the  occurrence  of  perforation,  a 
diffuse  extravasation  of  urine  is  prevented  in  one  direction  by  inflamma- 
tory condensation  of  cellular  tissue — in  another,  by  free  peritoneal  exu- 


174  ABNORMITIES    OF    THE 

dation  and  agglutination  to  an  adjoining  organ.  The  circumscribed  sup- 
puration progresses  slowly,  and  induces  fistulous  destruction  of  the  tissues, 
and  communications  between  the  bladder  and  the  external  surface  of  the 
body,  or  with  other  hollow  organs. 

Catarrh  of  the  bladder  is  of  importance,  under  all  circumstances,  from 
its  extension  to  the  ureters ;  and,  in  bad  cases,  from  its  complication  with 
renal  inflammation.  It  may  also  extend  to  the  seminal  ducts. 

A  very  important  variety  of  vesical  inflammation  is  that  developed  in 
the  course  of  paraplegia ;  it  generally  passes  into  gangrene,  and  termi- 
nates fatally.  The  mucous  membrane  becomes  the  seat  of  extensive  con- 
gestion and  suffusion,  which  spread  to  the  submucous  cellular  tissue  and 
the  muscular  layer ;  the  bladder  assumes  a  dark-red  hue,  is  friable,  dilated, 
and  filled  with  urine  ;  or  it  is  empty  and  collapsed,  and  the  mucous  mem- 
brane is  then  partly  invested  with  a  coat  of  ill-looking  lymph,  partly  in- 
filtrated with  pus,  partly  fused  into  a  pulpy  sanious  tissue.  The  mus- 
cular fasciculi  are  pallid,  ash-colored,  and  friable,  and  the  cellular  tissue 
is  infiltrated  with  pus  and  sanies.  The  cavity  of  the  bladder  contains  a 
sanguineous,  dirty  brown,  or  chocolate-colored  urine,  of  a  pungent  amtno- 
niacal  odor ;  this  is  mixed  up  with  the  various  products  of  the  process, 
and  deposits  a  white,  soft,  pulverulent  sediment. 

This  affection  presents  an  extremely  asthenic  character,  and  although 
we  are  ready  to  admit  that  in  many  cases  it  originates,  together  with  the 
concurrent  inflammation  of  the  kidneys,  in  paralysis,  we  consider  that  in 
others  the  irritation  produced  by  the  alkaline  urine  stagnating  in  the 
bladder,  is  to  be  viewed  as  the  chief  or  as  a  collateral  cause. 

b.  JExudative  processes. — Primary  croup  of  the  vesical  mucous  mem- 
brane is  extremely  rare ;  but  secondary  exudative  processes  are  by  no 
means  as  unusual  as  is  commonly  thought.  The  latter  occur  during  the 
course  of  exanthematic  diseases,  especially  of  scarlatina  and  variola, 
during  typhus  as  a  symptom  of  an  anomaly  and  degeneration  of  the 
typhous  process,  in  consequence  of  absorption  of  pus  in  the  blood,  and 
associated  with  exudative  processes  in  other  mucous  membranes. 

The  affection  gives  rise  to  a  more  or  less  coagulable  fibrinous  exuda- 
tion of  varying  thickness,  or  to  a  viscid,  gelatinous,  discolored,  purulent, 
or  sanious  product ;  it  rarely  involves  the  entire  bladder,  or  even  a  large 
portion  of  it,  but  is  generally  limited  to  round  spots  or  striae.  The  mu- 
cous membrane  presents  the  most  various  degrees  of  injection  and  red- 
ness, varying  from  an  almost  imperceptible  change  to  complete  saturation 
of  some  portions,  with  considerable  thickening  and  tumefaction,  and  an 
induration  proportionate  to  the  coagulability  of  the  deposit.  According  to 
the  character  of  the  process,  the  diseased  tissue  becomes  softened  and 
converted  into  a  pale  or  dark-red,  reddish-brown  pulp,  or  a  gelatinous, 
purulent,  or  sanious  mass ;  the  local  process  not  unfrequently  assumes 
a  gangrenous  character^  and  the  tissues  are  then  resolved  into  a  putre- 
scent  sanies,  or  become  detached  in  the  shape  of  an  eschar. 

As  the  exuded  matter  coagulates,  it  not  unfrequently  takes  up  urinary 
sediments,  or  these  are  subsequently  deposited,  and  give  rise  to  an 
incrusted  appearance  of  the  coagula  or  of  the  bladder. 

We  see  the  typhous  process  occurring  in  the  vesical  mucous  membrane 
under  various  forms : 


URINARY    BLADDER.  175 

a.  It  is  rarely  presented  in  the  genuine  shape,  i.  e.  characterized  by  a 
product  resembling  that  formed  in  the  intestinal  follicles  and  in  the 
mesenteric  glands. 

/5.  It  is  frequently  met  with  as  a  degenerate  exudative  process  in  the 
shape  of  scattered,  insulated,  and  soft  exudations. 

Y.  It  is  seen  degenerated  to  an  exudative  process  resembling  a  gan- 
grenous eschar.  Opportunities  of  observing  the  complete  metamorphosis 
of  the  products  and  their  subjacent  strata,  in  the  shape  of  softening, 
fusion,  and  separation,  are  but  rarely  offered,  as  the  general  disease  com- 
monly proves  fatal  prior  to  these  events. 

c.  Pustular  inflammation. — We  advert  to  the  rare  formation  of  vario- 
lous  pustules  upon  the  authority  of  other  observers.     We  have  ourselves 
not  seen  pustules  in  the  bladder,  even  in  cases  in  which  the  urethral 
mucous  membrane  was  intensely  affected  by  the  variolous  disease. 

We  may  at  the  same  time  mention  the  occurrence  of  small  millet-seed 
vesicles  containing  a  clear  serosity,  and  resembling  a  miliary  eruption  ; 
they  accompany  catarrhal  inflammation  and  slight  exudative  processes  in 
the  vesical,  in  the  same  manner  as  in  other  mucous  membranes,  and  are 
noticed  chiefly  at  the  fundus  and  neck  of  the  bladder.  It  is  also  an  in- 
teresting fact  that  we  have  found  them  in  many  cases  of  Asiatic  cholera, 
accompanied  by  painful  dysuria,  for  which  alkaline  fomentations  afforded 
considerable  relief. 

d.  Pericystitis. — We  have  already  alluded  to  the  more  or  less  diffused 
inflammation  of  the  cellular  tissue  surrounding  the  bladder,  which  super- 
venes upon  intense  inflammation  of  the  muscular  coat  and  suppuration  of 
the  bladder  (vide  p.  173),  or  is  the  result  of  infiltration  of  urine  after 
accidental  or  intentional  wounds  of  the  bladder,  of  ulcerative  perforation, 
and  of  an  extension  of  inflammation  from  adjoining  cellular  structures ; 
but  we  have  besides  these  a  spontaneous  inflammation  of  the  cellular 
tissue  surrounding  the  bladder,  which  is  designated  as  pericytt&i*.    Like 
the  inflammatory,  suppurative,  and  gangrenous  processes  of  the  subcu- 
taneous cellular  tissue,  or  of  the  cellular  tissue  surrounding  the  caecum 
or  rectum,  it  may  be  idiopathic,  though  it  is  more  frequently  a  secondary 
process ;  it  is  to  be  considered  as  a  localization  of  pyaemia,  which  was 
either  spontaneous  or  dependent  upon  an  absorption  of  pus,  or  of  a  dege- 
nerate typhous  or  anomalous  exanthematic  process.     It  spreads  with 
facility  through  the  cellular  tissue  of  the  pelvis,  to  the  cellular  septum  of 
the  rectum,  to  the  anus,  and  into  the  scrotum ;  it  attacks  the  submucous 
tissue  of  the  bladder,  and  having  passed  into  suppuration  and  necrosis, 
causes  an  exfoliation  of  the  mucous  membrane  and  perforation  of  the 
vesical  parietes. 

The  affection  is  sometimes  of  a  chronic  nature,  and  then  gives  rise  to 
induration,  callosity,  and  rigidity  of  the  bladder. 

3.  Gangrene  of  the  bladder. — Gangrene  is  the  result  of  intense  inflam- 
mation, brought  on  by  the  contact  or  imbibition  of  anomalous  urine  in  the 
affected  tissues,  in  which  cases  it  assumes  the  appearance  of  sphacelous 
fusion  (vide  p.  173) ;  or  it  results  from  contusion,  and  then  we  find  an 
eschar  formed  (vide  p.  174), 

4.  Softening. — Besides  the  fusion  of  the  mucous  membrane  accom- 
panying the  exudative  process,  we  have  but  once  observed  a  gelatinous 


176  ABNORMITIES    OF    THE 

softening  of  the  vesical  mucous  membrane.  It  occurred  in  a  case  of 
typhus  which  had  reached  the  ulcerative  stage,  and  the  bladder  was 
found  to  contain  a  large  quantity  (three  pounds)  of  putrescent  urine. 

5.  Adventitious  growths. — a.  We  have  never  observed  the  formation 
of  cysts  between  the  coats  of  the  bladder,  or  in  its  mucous  membrane, 
though  from  their  occurrence  in  the  ureters,  pelvis,  and  calices  (vide  p. 
167),  we  are  not  inclined  to  dispute  the  possibility  of  the  former.  We 
have  to  remark  that  the  accounts  of  a  discharge  of  hydatids  or  acepha- 
locysts  from  the  bladder  for  the  most  part  depend  upon  a  descent  of 
these  growths  from  the  kidneys,  or  from  other  organs  (e.  g.  the  liver), 
that  have  formed  adhesions  with  the  urinary  passages,  to  the  bladder, 
from  which  they  are  eliminated. 

b.  Tubercle. — Tubercle  of  the  vesical  mucous  membrane  is  a  very 
rare  occurrence,  and  is  not  even  always  found  as  a  complication  of  tu- 
bercular affection  of  the  urinary  apparatus,  which,  as  we  have  already 
seen,  is  combined  with  and  results  from   tuberculosis  of  the   sexual 
organs.     When  it  presents  itself  on  the  vesical  mucous  membrane,  it  is 
commonly  also  associated  with  tubercle  of  the  urethra  and  prostate 
gland. 

It  assumes  the  form  of  discrete  granulation  only,  and  is  deposited, 
with  more  or  less  reaction  and  vascularity,  under  the  mucous  membrane ; 
it  becomes  softened  with  greater  or  less  rapidity,  and  after  perforating 
the  mucous  membrane  within  a  vascular  area,  leaves  a  small  circular 
ulcer.  According  to  our  observations,  and  owing  probably  to  the  rapid 
development  of  the  tubercular  disease  in  the  other  segments  of  this  and 
the  sexual  system,  as  well  as  to  the  high  degree  of  the  universal  cachexia, 
secondary  tubercular  deposition  and  secondary  enlargement  of  the  tu- 
bercular ulcer  in  the  bladder,  are  found  to  be  very  unusual.  The  cervix 
and  fundus  of  the  bladder  are  the  main  seat  of  tubercle  ;  we  sometimes 
however  notice  that  the  bladder  is  involved  in  secondary  tubercular 
ulceration  by  an  extension  of  the  disease  from  the  prostate  gland. 

c.  Carcinoma. — The  bladder  is  either  attacked  primarily  by  cancer, 
or  the  disease  is  consecutive,  having  spread  from  neighboring  organs, 
especially  the  uterus,  the  vagina,  and  the  rectum.     The  latter  is  by  far 
the  more  common  case. 

We  have  observed  the  following  varieties  of  cancer : 

«.  Fibrous  cancer  occurs  but  rarely  in  the  shape  of  cancerous  degene- 
ration of  the  vesical  membranes  with  thickening,  cartilaginous  indura- 
tion, and  the  characteristic  metamorphosis  of  the  muscular  layer ;  we 
have  seen  it  spread  over  large  surfaces,  at  the  side  of  the  bladder,  both 
upwards  and  downwards,  accompanied  by  carcinomatous  degeneration  of 
the  female  urethra. 

/3.  Medullary  cancer  occurs  in  the  shape  of  nodulated  morbid  growths 
between  the  coats  of  the  bladder,  and  is  commonly  associated  with 
cancer  in  the  adjoining  sexual  organs  of  the  female,  and  with  cancer  of 
the  rectum.  It  perforates  the  mucous  membrane,  and  occasionally  gives 
rise  to  a  characteristic  carcinomatous  ulcer  with  raised  edges. 

Y'  The  most  frequent  form  of  cancer  occurring  in  the  bladder  presents 
the  appearance  of  soft,  furred,  cauliflower-like,  vascular,  and  generally 
bluish-red  vegetations,  which  bleed  on  the  slightest  touch,  and  are  at- 


THE    URETHRA.  177 

tached  by  a  rounded  flattened  peduncle ;  they  arise  from  the  mucous 
membrane  and  the  submucous  cellular  tissue  with  delicate  fibres,  and 
develope  a  very  fine  membranous  tissue,  within  which  a  whitish  or  red- 
dish-white, creamy  or  medullary  {encephaloid)  mass  is  formed.  They  are 
either  isolated  or  grouped  together,  and  at  last  coalesce  so  as  to  form  a 
very  large,  loose,  fissured,  succulent,  globular  mass  (fungus),  which  fills 
out  the  bladder  in  proportion  as  the  latter  becomes  hypertrophied  and 
contracted,  in  consequence  of  the  permanent  irritation.  They  chiefly 
occupy  the  neck  and  fundus,  the  trigonum  and  the  parts  near  the  ure- 
thral  orifices  ;  they  are  sometimes  spread  over  the  entire  inner  surface 
of  the  bladder,  but  they  generally  make  their  first  appearance  at  the 
above-named  spots,  and  it  is  there  too  that  the  large  fungoid  growths 
are  found.  Of  several  cases  we  may  mention  one  in  which  these  vege- 
tations occupied  and  nearly  filled  the  cavity  of  a  diverticulum  of  the 
size  of  a  duck's  egg,  which  descended  from  the  fundus  of  the  bladder  to 
the  rectum  and  perineum. 

The  more  they  are  developed,  the  more  they  are  liable  to  produce 
considerable  hemorrhage  from  their  extreme  vascularity ;  with  conse- 
quent cachexia  and  exhaustion ;  they  are  occasionally  found  inflamed, 
covered,  and  interlaced  with  lymphatic  exudation,  and  gangrenous. 

This  variety  of  cancer  is  frequently  complicated  with  cancer  in  other 
organs ;  it  is  especially  allied  to  the  cauliflower  excrescences  occurring 
upon  anomalous  serous  and  fibro-serous  membranes,  and  upon  the  inner 
surface  of  the  compound  cystoidea  or  of  the  peripheral  follicles  of  areolar 
cancer  that  have  been  converted  into  large  sacs  ;  as  also  to  erectile  tumors 
or  epithelial  formations  on  other  mucous  membranes. 


SECT.  IV. — ABNORMITIES  OF  THE  URETHRA. 

§  1.  Defective  Development. — The  urethra  is  absent  in  those  rare 
cases  in  which  the  entire  uropoietic  system  is  wanting,  as  also  in  those 
in  which  the  bladder  is  deficient ;  it  is  also  wanting  in  those  cases  in 
which  there  is  a  partial  deficiency  of  the  bladder,  as  in  cases  of  fissure, 
of  ectrophy  in  the  female  sex,  and  of  cloacal  formation.  The  urethra 
may  be  imperfectly  developed,  presenting  on  the  upper  (epispadiasis)  or 
lower  (hypospadiasis)  surface  of  the  penis,  a  fissure  which  extends  either 
along  its  entire  length,  or  only  to  a  short  distance  from  the  external 
orifice ;  fissure  of  the  entire  dorsal  surface  of  the  penis  occurs  as  a  com- 
plication of  eversion  of  the  bladder,  that  of  the  inferior  surface  with 
fissure  of  the  scrotum.  The  latter  malformation  causes  a  resemblance 
to  the  vagina.  In  other  cases  a  portion  of  the  urethra  is  deficient,  and 
the  latter  then  terminates  in  a  cul-de-sac,  placed  at  a  greater  or  less 
distance  from  the  usual  point  of  the  orifice  in  the  glans  penis  ;  total  ab- 
sence of  the  urethra  equally  gives  rise  to  an  imperforate  penis. 

The  urethra  may,  in  consequence  of  a  congenital  arrest  of  develop- 
ment, not  open  externally,  but  communicate  with  the  cavity  of  the 
rectum,  or  in  the  female  sex  with  the  vagina  ;  or  vice  versa,  it  may 
receive  the  rectum  or  vagina  at  the  lower  or  posterior  portion  of  its 
parietes. 

VOL.  II.  12 


178  ABNORMITIES    OF 

§  2.  Deviations  of  Size. — They  affect,  with  exception  of  congenital 
shortness  of  the  urethra,  its  calibre  only.  We  find  a  more  or  less  di- 
lated or  contracted  condition  of  the  urethra  occurring  in  both  sexes  as 
a  congenital  anomaly,  and  affecting  its  entire  extent  or  small  portions 
only  ;  it  is  of  especial  importance  in  the  male  sex. 

Dilatations  as  well  as  contractions  of  the  urethra,  the  latter  being 
particularly  frequent  and  important,  occur  as  acquired  conditions. 

Dilatation  affects  the  entire  canal  uniformly  or  detached  spots  only ; 
this  depends  upon  the  locality  of  a  mechanical  impediment,  and  upon 
the  extensibility  of  various  portions  of  the  urethra.  The  pars  membra- 
nacea  of  the  male  urethra  is  liable  to  the  largest  fusiform  and  pouchy 
dilatations ;  a  uniform  dilatation  of  the  entire  canal  is  often  brought  on 
by  the  continued  use  of  bougies. 

Contractions  of  the  urethra  originate  in  primary,  but  more  frequently 
in  secondary,  textural  changes  of  the  urethral  mucous  membrane  of  the 
corpus  cavernosum  and  its  fibrous  sheath,  and  we  shall  have  to  examine 
them  more  carefully  when  speaking  of  urethral  inflammation  and  its  con- 
sequences. 

Contractions  of  the  urethra  are  also  brought  on  in  either  sex  by  the 
pressure  of  morbid  growths,  in  man  by  the  enlarged  prostate,  in  the 
female  by  neighboring  organs  that  have  been  dislocated,  e.  g.  the  uterus, 
the  prolapsed  vagina,  &c.  The  passage  of  the  urethra  may  also  be  more 
or  less  permanently  or  dangerously  narrowed  or  closed  up  by  products 
of  its  own  mucous  membrane,  as  well  as  that  of  the  bladder,  e.  g.  a 
mucous  plug,  croupy  exudation,  renal  and  vesical  calculi,  acephalo- 
cysts,  &c. 

§  3.  Deviations  of  Direction. — Among  these  we  reckon  the  serpen- 
tine, angular  or  inflected,  and  variously  altered  course  given  to  the 
urethra  by  voluminous  hernise  in  either  sex,  by  large  morbid  growths  in 
the  vicinity,  by  the  dislocation  of  neighboring  organs  (the  uterus)  in  the 
female,  and  especially  by  the  enlarged  prostate  in  man  ;  the  latter  causes 
a  contraction  of  the  urethra,  and  pushes  it  aside,  or  divides  it  into  two 
passages,  which  diverge  in  the  direction  of  the  bladder. 

Both  the  pressure  which  the  urethra  suffers,  as  well  as  the  anomalous 
direction,  and  particularly  the  inflection  induced,  diminish  the  calibre 
of  the  urethra  at  various  points. 

§  4.  Solutions  of  Continuity. — We  enumerate  under  this  head,  wounds 
of  the  urethra,  contusions  and  rupture  brought  on  by  a  concussion  or 
fall,  particularly  upon  the  perineum  ;  rupture  produced  by  the  passage 
of  large  angular  calculi,  perforations  brought  on  by  rude  efforts  at 
catheterization,  and  ulcerative  destruction.  In  all  these  cases  incom- 
plete recovery  very  often  takes  place,  leaving  urinary  fistulse  of  vary- 
ing extent,  length,  direction,  and  course. 

§  5.  Diseases  of  the  Tissues. 

1.  Inflammation,  a.  Catarrhal  inflammation. — It  commonly  com- 
mences with  a  more  or  less  acute  or  inflammatory  stage,  and  subsequently 
passes  into  a  protracted  or  chronic  (blennorrhoic)  stage.  It  results  from 


THE     URETHRA.  179 

chemical  or  mechanical  irritation  by  substances  that  have  been  intro- 
duced from  without,  or  it  may  be  developed  spontaneously  in  children 
from  a  scrofulous,  or  in  aged  people  from  a  gouty  diathesis,  and  in  either 
it  may  be  connected  with  impetigo  ;l  though  it  has  its  origin  most  fre- 
quently in  gonorrhoeal  contagion  (gonorrhoeal  catarrh). 

We  find  the  anatomical  characters  to  be  those  belonging  to  catarrh 
generally  ;  in  the  acute  stage  there  is,  according  to  the  violence  of  the 
process,  redness,  injection,  tumefaction  of  the  urethral  mucous  membrane, 
or  secretion  of  puriform  mucus  ;  in  the  chronic  stage  there  is  tumefac- 
tion of  the  mucous  membrane,  enlargement  of  the  follicles,  relaxation  of 
the  sinuses,  and  a  white  or  colorless  secretion.  The  inflammation  is 
either  uniformly  diffused  over  the  urethra,  or  is  limited  to  one  or  more 
spots.  The  latter  is  especially  the  case  in  genuine  gonorrhoea  of  the 
male  urethra ;  we  here  find  not  only  the  navicular  fossa,  but  every  point 
as  far  as  the  prostatic  portion,  and  especially  the  vicinity  of  the  bulb  of 
the  urethra,  liable  to  become  the  seat  of  the  disease.  When  the  gonor- 
rhoea is  very  violent  and  obstinate,  a  small  tubercular  swelling,  which 
results  from  the  deposition  of  fibrinous  matter  in  the  spongy  tissue  of 
the  urethra,  is  found  at  these  points  of  the  urethra.  This  subject  has 
not  hitherto  received  the  attention  it  deserves,  either  in  regard  to  gonor- 
rhoea itself,  or  in  reference  to  the  pathology  of  stricture  consequent  upon 
gonorrhoea,  and  to  the  gonorrhoeal  ulcer  of  the  urethra. 

The  terminations  and  consequences  of  gonorrhoea  are  various.  The 
most  common  result,  which  is  caused  by  great  violence  of  the  affection, 
by  improper  dietetic  and  therapeutic  treatment,  and  by  repeated  attacks, 
is  condensation  and  hypertrophy  of  the  submucous  tissue,  fusion  of  the 
latter  with  the  mucous  membrane,  and  conversion  of  the  corpus  caver- 
nosum  into  a  white,  resistant,  fibrous,  cartilaginous  tissue.  The  entire 
urethra  sometimes  undergoes  this  metamorphosis,  subsequent  to  repeated 
and  mismanaged  attacks  of  gonorrhoea,  but  more  commonly  detached 
portions  only  are  affected,  and  this  gives  rise  to  partial  contraction  or 
stricture. 

Stricture  of  the  urethra  occurs  in  various  shapes :  the  urethra  is  some- 
times contracted  to  the  extent  of  several  lines,  the  parietes  presenting 
a  cartilaginous  appearance,  and  the  lining  membrane  being  either  smooth 
or  having  nodulated  projections,  or  longitudinal  folds  ;  sometimes  the 
stricture  forms  a  rounded  protuberance  or  an  angular  band  encircling 
the  entire  canal  or  only  surrounding  a  portion  of  the  circumference ;  at 
others,  again,  it  appears  in  the  shape  of  an  irregular  cicatrix,  which 
causes  the  surrounding  mucous  membrane  to  be  puckered  up. 

The  strictures  may  be  solitary,  or  after  a  recurrence  of  gonorrhoeal 
attacks,  there  may  be  two,  three,  four,  and  more.  Their  seat  corre- 
sponds to  the  seat  of  the  previous  inflammation.  We  have  a  unique 
preparation  in  the  museum  of  Vienna,  of  a  urethra  of  a  man  who  had 
repeatedly  been  affected  with  gonorrhoea;  it  presents  numerous  cartila- 
ginous protuberances  from  the  size  of  a  millet-seed  to  that  of  a  pea,  in 
part  coalescing  and  scattered  over  the  inner  surface,  as  far  back  as  the 
bulb,  leaving  the  passage  however  of  adequate  dimensions. 

1  [See  note,  p.  22.— ED.] 


180  ABNORMITIES    OF 

The  degree  attained  by  the  stricture  varies ;  we  not  unfrequently  find 
it  so  excessive,  that  the  contracted  part  scarcely  permits  the  passage  of 
the  finest  bristle. 

The  essential  character  of  stricture  consists  in  the  same  alterations  of 
this  submucous  and  mucous  tissue  which  we  observe  accompanying 
and  following  violent  inflammation  of  the  mucous  membranes,  when 
it  involves  the  submucous  cellular  tissue ;  it  does  not  bear  any  specific 
character.  The  inflammation  attacks  the  spongy  substances  of  the 
urethra  at  those  spots  at  which  the  diseased  action  was  most  deve- 
loped, and  gives  rise  to  a  deposit  of  the  fibrinous  matter  in  its  meshes, 
which  induces  the  above-mentioned  swellings  in  the  urethra.  If  reso- 
lution does  not  ensue  this  product  remains,  and  the  corpus  cavernosum  is 
converted  above  it  into  a  wheal,  varying  in  extent,  shape,  and  thickness, 
and  consisting  of  fibrous  and  fibroid  tissue ;  this  is  the  more  liable  to  in- 
duce a  narrowing  of  the  urethra,  as  it  possesses  a  great  tendency  to  con- 
tract, and  the  liability  increases  in  proportion  as  the  sound  layer  of  the 
corpus  cavernosum  diminishes.  The  stricture  is  most  considerable  when 
the  corpus  cavernosum  is  involved  throughout  its  entire  thickness.  It  is 
evident  that  when  the  metamorphosis  affects  the  innermost  layer  of  the 
corpus  cavernosum  only,  the  gonorrhoea  may  be  followed  by  dilatation 
of  the  urethra,  and  we  actually  find  this  to  be  the  case  in  violent  though 
diffused  gonorrhoea. 

The  stricture,  consequently,  consists  of  the  corpus  callosum  urethras, 
which  is  converted  into  a  fibroid  callus  with  which  the  mucous  membrane, 
including  its  epithelial  and  submucous  layer,  has  become  identified.  It 
is  in  no  way  related  to  cancer,  and  particularly  not  to  so-called  scirrhus. 
However,  mechanical  irritation  frequently  brings  on  excoriation,  inflam- 
mation of  the  tissue,  and  ulceration,  which  in  favorable  cases  may  be 
put  a  stop  to  after  the  passage  of  the  urethra  has  been  re-established, 
though  it  often  involves  the  deeper  parts,  destroys  the  urethra,  and  in- 
duces urinary  fistulse. 

Strictures  maintain  a  tendency  in  the  urethral  mucous  membrane  to 
inflammatory  attacks,  which  gradually  extend  to  the  bladder,  the  urinary 
passages,  and  the  seminal  ducts.  They  also  lead  to  a  dilatation  of  the 
urethra  beyond  the  contracted  part,  to  dilatation  and  hypertrophy  of  the 
bladder,  and  dilatation  of  the  ureters. 

Those  excrescences  which  are  termed  warts  by  medical  practitioners, 
and  which  are  probably  polypous  or  condylomatous  growths  of  the 
urethral  mucous  membrane,  and  which  are  said  to  be  particularly  liable 
to  accompany  stricture,  are  another  consequence  of  gonorrhoea.  We 
have  observed  them  very  rarely. 

Lastly,  we  find  gonorrhoeal  inflammation  degenerating  into  ulceration, 
causing  the  gonorrhoeal  ulcer,  which  has  not  been  as  yet  sufficiently  in- 
vestigated in  the  dead  subject,  and  which  not  unfrequently  gives  rise  to 
very  fine  capillary  fistulse. 

True  polypi,  particularly  of  the  female  urethra,  probably  occur  as  a 
consequence  of  repeated  and  tedious  catarrhal  affections.  I  have  found 
them  in  one  preparation  in  the  prostatic  portion  of  the  male  urethra. 

b.  JEJxudative  processes. — In  very  rare  cases  we  find  primary  croup  oc- 
curring on  the  urethral  mucous  membranes ;  it  induces  a  circumscribed 


THE    URETHRA.  181 

or  a  tubular  exudation,  according  to  the  intensity  of  the  process,  and 
occurs  chiefly  in  children. 

In  the  course  of  hectic  fever,  brought  on  by  suppuration  in  the  vicinity, 
we  occasionally  see  more  or  less  numerous  aphthous  exudations  and  ero- 
sions on  the  urethral  mucous  membrane. 

c.  Pustular  inflammation. — We  frequently  observe  variolous  pustules 
in  the  urethra,  when  the  disease  is  very  intense  on  the  general  tegumen- 
tary  surface.  As  in  other  mucous  membranes,  it  is  accompanied  by  an 
exudative  process  of  varying  intensity. 

2.  Ulcerative  processes. — Besides  the  gonorrhoea!  ulcer,  the  ulcerating 
stricture  and  the  ulcerative  processes,  with  which  the  urethra  is  attacked 
from  without  (the  prostate),  and  to  which  it  is  more  or  less  exposed  in 
conjunction  with  the  penis,  we  have  to  notice  the  primary  syphilitic  ulcer 
— chancre  of  the  urethra.     Cicatrices  left  by  ulceration,  and  especially 
by  the  last  variety,  must  be  carefully  distinguished  from  gonorrhoeal 
stricture,  though  this  is  rendered  extremely  difficult,  as  the  cicatrix  almost 
invariably  induces  stricture. 

3.  Adventitious  formations. — In  addition  to  the  fibroid  tissues  occur- 
ring after  gonorrhoeal  inflammation,  and  especially  in  strictures,  to  the 
problematic  carunculge  or  warts  of  the  urethra,  we  find  that  tubercle  and 
tubercular  ulceration  (Tuberculosis  urethrse)  are  formed  in  the  urethra, 
though  only  in  conjunction  with  tuberculosis  of  the  entire  urinary  appa- 
ratus.    The  urethra  is  also  attacked  by  cancer  and  cancerous  ulceration ; 
in  the  male  sex  this  accompanies,  or  is  the  consequence  of,  carcinoma  of 
the  penis,  and  especially  of  the  glans. 

§  6.  Anomalous  Contents  of  the  Urinary  Passages. — The  anomalous 
contents  of  the  urinary  passages  are  very  various,  and  may  be  classified 
as  follows : 

1.  The  products  of  the  organic  affections  of  the  secretory  as  well  as 
the  efferent  apparatus ;  they  are  the  more  intimately  mixed  with  the 
urine,  the  nearer  the  point  of  their  formation  is  to  the  place  where  the 
latter  is  secreted,  and  the  greater  their  capability  of  suspension  and 
their  solubility. 

2.  The  deviations  which  the  urine  presents,  independent  of  the  first- 
mentioned  admixtures,  whether  accompanied  by  a  demonstrable  disease 
of  the  renal  texture,  or  unassociated  with  any  traces  of  structural  dis- 
ease :  they  result  from  an  anomaly  in  the  vegetative  sphere,  and  espe- 
cially in  the  blood ;  they  may  also  occur  as  a  passing  effect  of  certain 
indulgences,  and  they  relate  to  the  quantity  and  quality,  and  particularly 
to  the  physical  characters  of  the  urine. 

In  reference  to  1,  we  have  to  notice  : 

a.  The  blood  and  certain  of  its  component  parts.  The  former  (hsema- 
turia)  is  found  in  the  urinary  passages,  to  a  larger  or  smaller  amount, 
in  the  shape  of  rounded  or  cylindrical  coagula  of  varying  consistency,  or 
mixed  with  the  urine  in  a  fluid  condition.  It  appears  in  consequence  of 
various  injuries  involving  the  kidneys  and  the  urinary  apparatus,  pro- 
duced by  means  of  cutting  instruments,  concretions,  ruptures,  apoplexy 
of  the  kidney,  the  bursting  of  an  aneurism  into  the  urinary  passages,  or 
of  varicose  veins  into  the  bladder,  ulcerative  corrosion  of  a  vessel,  or 


182  ABNORMITIES    OF 

bleeding  carcinomatous  growths  in  the  urinary  organs.  It  results  from 
hypersemia,  nephritis,  Bright's  disease,  hemorrhagic  inflammation  of  the 
passages,  and  from  disorganization  of  the  blood.  Sometimes  it  is  not 
true  blood — blood-globules — but  mere  haematosine,  which  passes  into  the 
urine  from  the  serum  in  the  kidneys.  We  also  find  other  constituents  of 
the  blood,  such  as  albumen  and  fibrine,  in  the  urine. 

Albumen  is  discovered  in  the  course  of  numerous  diseases  both  accom- 
panied by  and  unassociated  with  renal  disease.  In  many  acute  diseases, 
albuminous  urine  is  secreted  with  an  excess  of  lithic  acid,  and  lithate  of 
ammonia.  Albumen  is  sometimes  found  with  sugar  in  diabetic  urine  ;  it 
always  occurs  in  hemorrhage  into  and  inflammation  of  the  urinary  pas- 
sages, in  hypersemia,  nephritis,  &c.  It  is  found  to  a  large  amount  in 
Bright's  disease  of  the  kidney,  frequently  mixed  up  with  blood-globules, 
or  hsematosine.  Its  presence  is  demonstrated  by  milky  turbidity  of 
urine,  by  the  urine  foaming  when  air  is  blown  into  it,  by  coagulation  of 
the  albumen  on  the  application  of  heat,  the  addition  of  alcohol  or  nitric 
acid,  &c. 

Fibrine  is  said  to  have  been  found  in  the  urine  in  some  cases  of 
dropsy ;  in  the  case  of  hemorrhage  into  the  urinary  apparatus  it  forms 
coagula  of  various  shapes  and  sizes,  which  are  easily  recognized. 

b.  Exudations  in  the  urinary  passages,  assuming  the  shape  of  flocculi, 
laminse  and  tubular  concretions. 

c.  Grayish,  milky,  vitreous,  colorless,  purulent  yellow  (blennorrhoic) 
mucus,  pus  and  sanies,  may  be  intimately  blended  with  the  urine,  caus- 
ing it  to  be  variously  discolored  or  turbid,  or  forming  flocculent  concre- 
tions, and  loose,  crummy,  viscid,  glutinous  sediments.     Mucus  appears 
in  the  urine  as  the  effect  of  acute,  but  more  frequently  of  chronic  catar- 
rhal  inflammation  of  the  urinary  passages.     Pus  and  sanies   are  the 
result  of  suppuration  of  the  kidneys,  with  discharge  of  the  abscess  into 
the  urinary  passages,  and  of  suppuration,  and  the  formation  of  sanies  in 
the  latter  ;   or  these  fluids  reach  the  urinary  cavities  from  neighboring 
organs  by  ulcerated  communications  ;  they  may  also  be  the  consequence 
of  gangrene,  tubercular  or  cancerous  degeneration.     We  also  find  in  the 
urine,  besides  the  above-mentioned  substances,  epithelial  lamellae,  tuber- 
cular matter,  elementary  cells  of  cancer,  &c. 

d.  It  is  stated  that  the  urine  contains  a  substance  resembling  cerebral 
fat,  when  the  kidney  is  affected  with  medullary  cancer.     The  immediate 
condition  of  this  occurrence  has  not  as  yet  been  determined  ;  it  is  pro- 
bably essential  that  the  morbid  growth  should  have  forced  its  way  into 
the  urinary  passages,  or  that  it  should  project  into  them. 

e.  Ancient  and  modern  observers  have  noticed  that  hairs  are  some- 
times evacuated  with  the  urine  ;  they  may  be  formed  within  or  external 
to  the  urinary  organs. 

/.  Within  the  most  recent  period,  Curling  has  discovered  a  new  ento- 
zoon,  the  dactylius  aculeatus,  in  the  bladder.  A  very  recent  case  is 
also  given  of  the  discharge  of  cysticerci  with  the  urine ;  acephalocysts 
are  frequently  carried  into  the  urinary  passages  both  from  the  kidneys 
and  from  other  organs,  and  are  evacuated  with  the  urine. 

In  reference  to  2,  we  observe  that  the  deviations  of  the  urine,  as  re- 
gards quantity,  may  consist  in  excessive  or  diminished  secretion  ;  if  the 


THE     URETHRA.  183 

quantity  found  in  the  dead  subject  be  small,  it  is  requisite  to  ascertain 
the  evacuations  that  have  taken  place  before  death ;  if  considerable,  the 
obstacles  to  its  discharge  must  be  inquired  into.  Urine  presents  various 
anomalies  as  to  quality,  affecting  both  its  physical  and  chemical  pro- 
perties. 

a.  The  color  of  the   urine  is  either  too  intense,  owing  to  a  large 
amount  of  coloring  matter,  which  is  generally  combined  with  lithic  acid 
or  urea ;  or  it  is  very  pale,  and,  at  the  same  time,  less  acid  or  neutral. 
The  urine  assumes  a  red  color  from  an  admixture  of  blood  or  its  coloring 
matter ;  if  there  is  at  the  same  time  an  excess  of  acid,  it  may  become 
reddish-brown,  brownish-black,  or  in  very  rare  cases,  which  are  probably 
dependent  upon  an  alteration  in  the  hsematosine,  it  may  even  become 
perfectly  black.     Biliary  matter  produces  a  yellow,  yellowish-brown,  or 
even  greenish  discoloration.     We  must  finally  allude  to  those  anomalous 
appearances  of  the  urine  produced  by  the  consumption  of  various  sub- 
stances that  are  rich  in  coloring  matter,  as  beet-root,  madder,  rhubarb, 
gamboge,  chelidonium,  indigo,  ink.     The  urine  may  at  the  same  time 
be  transparent  or  turbid  ;  the  latter,  in  so  far  as  it  is  independent  of  the 
above-mentioned  foreign  admixtures,  is  proportionate  to  the  lithic  acid 
or  lithate  of  ammonia  contained  in  acid,  or  to  the  phosphates  in  alkaline 
urine. 

b.  The  odor  of  urine  is  either  more  or  less  powerful  than  in  the 
normal  condition ;  thus  the  pale  watery  urine  is  frequently  almost  with- 
out smell,  whereas  the  saturated  urine  of  acute  rheumatism  or  of  pneu- 
monia smells  very  strongly.     Occasionally  the  urine  presents  the  odor 
of  broth  or  of  whey  ;  in  diabetes  mellitus  it  has  a  spirituous  smell,  owing 
to  the  commencement  of  fermentation,  or  its  odor  resembles  that  of  de- 
composed straw,  of  putrid  matter,  or  is  very  pungent.     Different  odors 
are   perceived   after   the    consumption  of    asparagus,    turpentine,   the 
balsams,  leek,  assafoetida,   &c.     In  diabetes  mellitus,  the  urine  has  a 
sweet  taste. 

c.  Specific  gravity. — This  is  either  above  or  below  the  normal  stan- 
dard.    It  is   excessive  in  diabetes  mellitus,   and  very  low  in  diabetes 
insipidus.     In  the  chronic  form  of  Bright's  disease  it  is  diminished,  as 
the  proportion  of  urea  and  of  the  urinary  salts  is  diminished,  at  the 
same  time  that  the  albumen  increases ;  in  the  acute  form  it  is  not  unfre- 
quently  increased. 

3.  As  regards  the  chemical  composition  of  the  urine,  we  find  that  the 
normal  constituents  exist  in  irregular  proportions,  or  that  there  are  new 
and  unusual  substances. 

a.  The  watery  portion  of  the  urine  is  in  excess  in  numerous  affections 
of  the  nervous  system,  in  hysteria,  in  diabetes  insipidus,  and  according 
to  Rayer  and  older  observers,  in  advanced  age ;  its  quantity  is  too  small 
in  proportion  to  the  solid  constituents  in  the  saturated  urine  of  acute 
diseases,  especially  at  the  period  at  which  critical  discharges  occur. 

b.  The  urea  does  not,  as  was  formerly  believed,  bear  a  direct  relation 
to  the  coloring  matter  of  the  urine,  a  fact  that  has  been  distinctly  proved 
by  Prout  in  some  cases  of  diabetes  insipidus.     It  is  more  frequently 
morbidly  diminished,  as  in  diabetes  mellitus,  in  Bright's  disease,   and 
numerous  other  diseases  that  have  not  as  yet  been  clearly  diagnosed,  and 
in  which,  as  the  urea  disappears,  albumen  is  substituted. 


184  ABNORMITIES    OF 

Original  deficiency  of  urea  is  to  be  carefully  distinguished  from  that 
deficiency  which  results  from  its  decomposition  in  consequence  of  stag- 
nation in  the  urinary  passages,  from  the  influence  of  mucus,  purulent 
secretion,  and  pus. 

c.  Uric  acid,  either  free  or  combined  with  a  base,  and  especially  in 
the  shape  of  urate  of  ammonia,  is  deposited  in  the  form  of  small  crystals, 
or  of  a  yellow  or  lateritious  powder.     It  is  increased  in  quantity  in  rheu- 
matism, gout,  and  inflammatory  affections ;  in  hysterical  urine,  in  the 
urine  voided  during  the  cold  stage  of  intermittent  fever,  and  in  nume- 
rous other  diseases,  it  is  diminished  in  quantity.     If  free  acid  is  present 
in  the  urine  it  may  be  precipitated  in  the  shape  of  gravel,  though  not 
itself  in  excess. 

d.  The  phosphates  (phosphate  of  lime,  phosphate  of  magnesia,  and 
triple  phosphate  of  ammonia  and  magnesia)  are  often  present  in  excess. 
Phosphate  of  lime  is  deposited  in  the  absence  of  a  free  acid,  and  phos- 
phate  of  ammonia   and   magnesia,    as    a   basic    salt;    these  form  the 
phosphatic  sediments.     As  the  latter  salt  is  formed  in  consequence  of 
the  development  of  ammonia,  it  occurs  principally  in  urine  containing 
much  mucus,  pus,  seminal  fluid,  and  other  animal  substances  that  are 
easily  decomposed.     The  lithic  acid  is,  at  the  same  time,  proportionally 
diminished,  and  the  urine  is  neutral  or  alkaline. 

e.  The  alkaline  state  of  the  urine  is  of  extreme  importance  ;  in  many 
cases  that  have  not  as  yet  met  with  a  sufficient  explanation,  it  appears 
to  be  the  result  of  a  morbid  secretion,  or  it  depends  upon  decomposition 
of  the  urine,  and  presents  various  degrees.     The  urine  in  this  condition 
is  commonly  pale  and  turbid.     It  is  particularly  alkaline  in  chronic  in- 
flammation of  the  kidney,  and  in  numerous  diseases  of  the  urinary  pas- 
sages ;  it  is  so  sometimes  in  a  slight  degree,  and  temporarily,  in  Bright's 
disease.     The  alkaline  state  of  the  urine  in  diseases  of  the  spinal  cord, 
in  paraplegia,  has  attracted  some  attention,  and  has  given  rise  to  the 
question,  whether  this  alkalescence  is  the  result  of  a  simple  derangement 
of  the  act  of  secretion,  i.  e.  whether  the  urine  is  secreted  as  an  alkaline 
fluid ;  or  whether  an  acid  urine  becomes  alkaline  in  consequence  of  de- 
composition, by  means  of  the  products  of  coexistent  cystitis  or  nephritis. 
The  question  has  not  received  a  satisfactory  reply.     Post-mortem  exa- 
minations have  generally  demonstrated  the  existence  of  the  latter  series 
of  causes  of  alkaline  urine ;  the  examinations  of  the  urine  in  living  sub- 
jects have  been  either  neglected  in  the  class  of  cases  that  come  under 
this  head,  or  they  have  but  little  value,  on  account  of  the  insufficient 
diagnosis  of  existing  inflammation  of  the  urinary  passages  and  the  kid- 
neys.    The  only  proofs  in  evidence  of  alkaline  urine  being  secreted  by 
the  kidneys,  are  afforded  by  the  vivisections  of  Krimer  and  others,  in 
which,  after  the  division  of  the  spinal  cord,  urine  of  the  appearance  of 
pure  water  was  secreted ;  and  by  the  clear  neutral  or  alkaline  urine 
passed  in  hysterical  or  epileptic  attacks.     Rayer  has  found  the  urine 
acid  in  cases  of  recent  paraplegia,  unaccompanied  by  retention  of  urine. 

The  following  substances  are  rarely  found  as  constituents  of  the  urine : 
a.  Purpuric  acid,  a  modification  of  lithic  acid,  produced  by  the  pre- 
sence of  nitric  acid,  and  purpurates  (purpurates  of  ammonia  and  soda), 
which  are  said  to  give  a  red  color  to  the  urinary  sediments  (Prout). 


THE    URETHRA.  185 

/9.  Hippuric  acid  (Liebig),  which  has  been  found  in  children  in  the 
shape  of  hippurate  of  soda,  and  in  diabetes. 

Y.  Oxalic  acid  is,  according  to  Prout,  the  result  of  a  decomposition  of 
lithic  acid,  and  occurs  as  oxalate-  of  lime,  in  the  form  of  a  greenish  or 
blackish  sediment,  or  of  gravel  or  calculous  concretion. 

d.  Benzoic,  butyric,  and  cyanic  acid,  cyanurin  and  melanurin  in  blue 
and  black  urine,  xanthic  oxide  (Marcet),  and  cystin  (Wollaston). 

e.  Sugar,  in  varying  proportions,  in  diabetes  mellitus. 
C.  Cholesterin. 

T).  Numerous  medicinal  substances. 

The  formation  of  calculous  concretions  in  the  urinary  organs  is  a  mat- 
ter of  extreme  importance ;  it  takes  place  within  the  kidneys,  in  the 
pelvis  and  calices  of  the  kidneys,  in  the  ureters,  the  bladder,  the  urethra, 
the  urachus,  and  even  externally  to  these  passages.  The  pelvis  and  ca- 
lices of  the  kidney  and  the  bladder  are,  however,  the  parts  in  which  cal- 
culi are  most  frequently  formed.  The  latter  present  considerable  varie- 
ties, both  as  regards  their  physical  properties  and  their  chemical  compo- 
sition. 

aa.  When  the  concretions  are  very  small  they  are  termed  gravel,  and 
may  be  very  numerous  or  few  in  number.  Gravel  may  be  formed  at  any 
part  of  the  urinary  apparatus,  and  even  in  the  kidney.  The  red  variety 
consists  chiefly  of  lithic  acid,  the  white  of  phosphates.  Calculi  are  larger 
concretions,  which  again  differ  much  as  to  volume  and  weight.  In  size 
they  vary  from  that  of  a  millet-seed  to  that  of  a  goose's  egg,  or  a  fist. 

#3.  Vesical  calculi  are  generally  of  a  globular,  ovate,  or  oval  form; 
they  are  frequently  flattened  so  as  to  present  a  discoid  or  lenticular 
shape ;  if  two  or  more  coexist,  friction  planes  are  formed  giving  the  cal- 
culi when  numerous,  a  polyhedral  shape.  Large  renal  calculi  are  moulded 
according  to  the  form  of  their  nidus,  and  assume  a  branched  appear- 
ance. In  rare  cases  the  calculi  are  hollow,  forming  tubular  or  conchoid 
concretions.  Their  surface  is  either  smooth  or  rough,  angular  or  fis- 
sured ;  or  it  appears  decaying,  gnawed,  granular,  of  a  mulberry  form, 
or  set  with  sharp,  prickly  projections,  crystalline,  &c. 

77.  The  number  of  the  calculi  present  varies  ;  there  are  generally 
several  renal  calculi,  whereas  vesical  calculi  are  commonly  solitary ; 
however,  there  are  cases  on  record  in  which  fifty,  a  hundred,  nay, 
several  hundred  calculi,  especially  of  the  phosphatic  variety,  were  found. 

3d.  In  color,  consistency,  and  texture,  they  vary  much,  and  these 
qualities  depend  upon  their  chemical  composition. 

The  substances  entering  into  the  chemical  constitution  of  urinary  cal- 
culi are  numerous ;  sometimes  one  only  form  the  calculus  or  predomi- 
nates, at  others  several  are  mixed  up  together,  or  disposed  in  layers. 
They  are  not  all  equally  frequent. 

a.  Lithic  acid  enters  into  the  composition  of  most  calculi,  inasmuch  as 
many  consist  entirely  of  it,  many  in  part,  and  as  it  forms  the  nucleus  of  the 
majority.  Lithic-acid  calculi  are  commonly  of  considerable  hardness, 
smooth,  light  or  dark  brown,  rounded,  and  often  flattened. 

p.  Lithate  of  ammonia  and  lithate  of  soda  rarely  enter  into  the  com- 
position of  calculi.  Those  consisting  of  the  former  are  yellow,  and  of 
a  loose  texture ;  those  composed  of  the  latter  are  white  and  chalky. 


186  ABNORMITIES    OP 

Y.  Phosphate  of  lime  rarely  forms  a  calculus  by  itself. 

#.  Phosphate  of  ammonia  and  magnesia  forms  small,  friable,  white 
calculi,  that  have  a  shining  crystalline  investment. 

Calculi  consisting  chiefly  of  the  two  last-named  substances  and  car- 
bonate of  lime,  are  very  frequent.  They  are  white,  of  a  loose  texture, 
and  often  of  a  considerable  size ;  they  are  generally  formed  in  conse- 
quence of  inflammatory  affections  of  the  kidneys  and  urinary  passages, 
which  in  their  turn  are  frequently  induced  by  the  presence  of  a  lithic- 
acid  calculus,  or  some  other  foreign  body,  which  serves  as  a  nucleus  for 
the  calculous  deposit. 

&.  Oxalate  of  lime  forms  the  mulberry-shaped,  nodulated,  dark-brown 
or  black,  and  very  hard  calculi. 

C'.  Xanthic  oxide  and  cystine  are  very  rare.  The  latter  we  generally 
find  combined  with  fat,  resin,  coloring  matter,  iron,  silica.  In  rare 
cases  we  also  find  fibrinous  coagula,  in  the  shape  of  carneous  or  fibrous 
elastic  masses,  entering  into  the  formation  of  calculi. 

Vesical  calculi  are  either  contained  free  and  unattached  in  the  bladder 
or  are  firmly  grasped  by  the  bladder,  which  has  become  hypertrophied 
in  consequence  of  catarrhal  attacks.  They  are  found  encysted  in  hernial 
diverticula  of  the  bladder,  or  lie  in  saccular  expansions  of  the  vesical 
parietes,  which  they  form  for  themselves  during  the  contractions  of  the 
bladder ;  they  sometimes  become  agglutinated  to  these  and  other  parts 
by  means  of  fibrinous  exudations. 

Urinary  calculi  offer  mechanical  obstacles  to  the  conduction  and  dis- 
charge of  the  urine,  and  give  rise  to  inflammations  of  the  kidneys  and 
urinary  passages,  proportionate  to  the  size  of  the  calculi,  and  the  rough- 
ness and  irregularity  of  their  surface.  They  are  sometimes,  even  when 
of  considerable  magnitude,  discharged  by  the  natural  passages,  espe- 
cially in  the  female  ;  still  they  more  commonly  cause  severe  injuries  of 
the  urinary  channels,  rupture  of  the  urethra,  &c.  At  other  times  they 
make  their  way  by  inflammation  and  suppuration  into  neighboring  cavi- 
ties, as  into  the  rectum,  the  vagina,  or  into  abscesses,  and  from  these  by 
unnatural  passages  outwards. 

In  very  rare  cases  we  find  urinary  calculi  enclosed  in  cartilaginous 
capsules  external  to  the  urinary  passages,  having  either  forced  their  way 
out  of  the  latter  by  rupture  or  ulcerative  perforation,  or  having  been 
formed  at  the  spot  where  they  are  discovered,  in  urine  that  has  been 
previously  extravasated. 

Appendix. — Diseases  of  the  Suprarenal  Capsules. 

The  suprarenal  capsules  are  occasionally  deficient,  especially  when 
there  is  a  deficiency  in  other  organs  also.  They  are  not  always  absent 
in  acephalous  monstrosities ;  and  as  their  absence  generally  involves  the 
absence  of  numerous  other  organs,  the  fact  suggests  no  distinct  inter- 
pretation as  to  their  functions.  They  are,  moreover,  generally  present 
when  one  kidney  is  absent,  and  this  proves  that  they  are  perfectly  inde- 
pendent of  the  kidneys  and  the  sexual  organs  (Meckel) ;  their  diseases 
place  them  in  a  more  distinct  relation  with  the  lymphatic  glands. 


THE    URETHRA.  187 

The  fusion  which  often  occurs  in  the  kidneys  is  not  found  to  take 
place  in  the  suprarenal  capsules. 

Accessory  suprarenal  capsules,  indicating  an  apparent  excess  of  de- 
velopment, are  of  frequent  occurrence.  Several  flattened  acessory  su- 
prarenal capsules  are  then  found  in  the  renal  and  solar  plexuses,  and  on 
the  ganglion  of  the  latter,  varying  in  size  from  a  millet-  or  hemp-seed  to 
that  of  a  pea. 

They  are  occasionally  of  great  magnitude,  a  circumstance  which  calls 
their  foetal  condition  to  mind,  though  it  may  result  from  morbid  affec- 
tions. On  the  other  hand  they  may  be  small ;  and  this  may  equally  be 
the  consequence  of  a  congenital  or  an  acquired  anomaly.  A  reduction 
of  size  occurs  in  the  shape  of  marasmus  in  advanced  age,  or  at  an  earlier 
period  of  life ;  the  organ  shrivels  up,  becomes  tough  and  coriaceous,  its 
cortical  substance  assumes  a  dirty  yellow  color,  its  vascular  medullary 
substance  is  obliterated ;  or  in  some  cases  it  becomes  friable,  of  the  color 
of  the  lees  of  wine,  or  of  a  rusty  brown,  so  as  to  resemble  the  spleen  of 
old  persons.  The  atrophy  may  also  be  the  consequence  of  textural 
changes,  appearing  after  inflammation  in  the  shape  of  induration  or  obli- 
teration. 

The  form  of  the  suprarenal  capsules  is  subject  to  various  unimportant 
deviations ;  in  reference  to  their  position  we  have  to  remark,  that  they 
do  not  follow  the  congenital  dislocations  of  the  kidneys,  but  in  these 
cases  invariably  retain  their  normal  position. 

Their  textural  diseases  have  hitherto  met  with  little  consideration. 
Hemorrhage  not  unfrequently  occurs  in  them,  on  account  of  the  vascu- 
larity  of  their  medullary  substance.  The  suprarenal  capsule  is  found 
distended  in  proportion  to  the  amount  of  extravasation  caused  by  the 
rupture  of  a  vein ;  and  according  to  the  period  that  has  elapsed  since  the 
occurrence  of  the  hemorrhage,  we  find  the  blood,  more  or  less  discolored 
and  changed  in  constitution,  enclosed  within  the  cortical  substance,  which 
has  become  pale  and  atrophied,  and  is  finally  converted  into  a  fibroid 
layer. 

We  scarcely  ever  have  an  opportunity  of  observing  inflammation  of 
the  suprarenal  capsules,  except  in  its  terminal  stages,  suppuration  and 
induration.  Some  observers  have  found  the  suprarenal  capsules  con- 
verted into  purulent  pouches  in  the  new-born  infant,  and  even  in  the 
foetus  (Andral). 

The  morbid  growths  not  unfrequently  seen,  are :  tubercle  and  cancer- 
ous degeneration ;  both,  and  particularly  the  latter,  are  found  com- 
plicated with  similar  affections  of  other  organs,  and  especially  of  the 
lymphatic  glands. 

Tubercle  commonly  appears  deposited  in  the  suprarenal  capsules  in 
large  masses,  and  either  fuses  into  pus  enclosed  in  a  callous  sac,  or  is 
converted  into  a  chalky  concretion,  invested  by  a  fibroid  tissue,  in  which 
all  traces  of  the  proper  tissue  of  the  organ  have  disappeared. 

Cancer  commonly  appears  in  the  form  of  medullary  carcinoma,  which 
very  frequently  involves  the  neighboring  glands  of  the  lumbar  plexus, 
and  the  kidney,  and  causes  a  considerable  enlargement  of  the  suprarenal 
capsule.  Hemorrhage  occasionally  takes  place  within  the  parenchyma 


188  ABNORMITIES,    ETC. 

of  the  cancerous  growth,  and  causes  it  to  be  broken  down  into  a  choco- 
late-colored pulp. 

It  frequently  happens  that  the  suprarenal  capsules  become  adherent 
to  the  kidneys  in  consequence  of  inflammation,  or  of  other  diseases  asso- 
ciated with  inflammatory  reaction.  A  much  rarer,  though  very  interest- 
ing, occurrence  is  congenital  union  of  the  two  organs,  in  which  case  one 
tunica  albuginea  invests  the  two,  and  the  concave  surface  of  the  supra- 
renal capsule  adheres  to  the  kidney  by  means  of  short,  tense,  vascular, 
cellular  tissue. 


PART  III. 

ABNOEMITIES  OF  THE  SEXUAL  OKGANS. 


CHAPTER  I. 

ON  ABNORMITIES  OF  THE  SEXUAL  ORGANS  GENERALLY. 

THE  sexual  organs  are  occasionally  entirely  absent ;  a  defect  that  is 
commonly  associated  with  imperfect  development  of  other  parts,  and 
especially  with  acephalia  ;  a  more  or  less  important  section  of  the  appa- 
ratus is  often  defective,  and  one  of  the  symmetrical  organs,  or  one  half 
of  those  organs  which  unite  in  the  mesial  line,  may  he  absent ;  or  again, 
one  of  these  organs,  or  halves  of  organs,  may  be  imperfectly  developed, 
and  its  cavity  contracted  or  closed  up ;  or  the  apparatus  may  be  com- 
plete in  its  different  constituent  portions  and  not  have  been  duly  deve- 
loped, remaining  permanently  small  and  inefficient,  so  that  the  individual 
presents  no  sexual  character. 

Another  defect  of  the  sexual  organs  assumes  the  form  of  fissure,  which 
is  an  arrest  of  various  stages  of  embryonic  development.  The  highest 
degree  of  this  malformation  is  presented  in  the  cloaca,  which  is  to  be  ex- 
plained as  a  persistence  of  the  original  sinus  urogenitalis,  or  an  imperfect 
separation  of  the  parts  that  form  the  latter.  A  lower  degree  of  this 
species  of  deformity  is  presented  in  the  fissured  condition  of  the  sexual 
organs,  in  which  case  the  foetal  or  female  character  predominates ;  we 
allude  to  the  various  fissures  of  the  uterus,  of  the  vagina,  the  penis,  the 
urethra,  or  the  scrotum,  with  or  without  a  residuary  trace  of  the  urogeni- 
tal  sinus. 

From  these  latter,  apparently  hermaphroditic  formations,  which  de- 
pend upon  an  arrest  of  development,  those  pseudo-hermaphroditic  forma- 
tions, which  consist  in  an  excessive  development  of  certain  portions  of 
the  female  organs  of  generation  according  to  the  male  type,  form  a  transi- 
tion to  true  hermaphrodisia,  i.  e.  hermaphrodisia  per  excessum ;  in 
which  case  certain  portions  of  the  sexual  apparatus  of  an  opposite  sex 
are  superadded. 

In  addition  to  the  just-mentioned  excess  of  formation  we  meet  with 
another  form  in  the  shape  of  a  repetition  of  certain  sections  of  the  appa- 
ratus, which  may  either  present  itself  as  excessive  development  of  volume, 
or  as  precocity. 

Besides  congenital  deviations  of  size,  we  find  many  that  are  acquired ; 
in  addition  to  those  varieties  which  depend  upon  textural  diseases,  and 
particularly  upon  adventitious  growths,  they  occur  in  the  shape  of  hy- 
pertrophy and  atrophy.  The  uterus  in  the  female,  the  prostate  in  the 
male  sex,  are  particularly  liable  to  be  affected  by  the  former  ;  the  latter, 
independently  of  the  process  of  involution  (tabes  senilis),  which  more  or 


192  ABNORMITIES    OF    THE    TESTES 

less  uniformly  involves  the  generative  system,  especially  attacks  the 
testes  and  the  ovaries,  and  in  a  second  degree  the  uterus. 

The  sexual  organs  are  subject  to  numerous  congenital  deviations  as 
to  form ;  the  uterus  and  its  cavity  are  peculiarly  liable  in  the  female, 
the  prostate  in  the  male  sex,  to  acquired  malformations. 

The  position  of  the  external  sexual  organs  depends  upon  the  congenital 
or  acquired  degreee  of  inclination  of  the  pelvis,  and  other  malformations. 
The  most  important  congenital  deviation  of  position  of  single  organs 
affects  the  testes  ;  the  uterus  presents  very  important  acquired  irregu- 
larities of  this  class. 

Diseases  of  the  tissues  are  peculiarly  frequent  in  the  female  organs  of 
generation  ;  and  among  them  the  adventitious  growths  are  most  remark- 
able. We  shall  have  occasion  to  advert  in  detail  to  many  points  of  in- 
terest, relative  to  the  morbid  growths  occurring  in  the  sexual  organs  of 
either  sex. 


CHAPTER  II. 

ABNORMITIES  OF  THE  MALE  ORGANS  OF  GENERATION. 
SECTION  I. — THE   TESTES  AND   VASA   DEFERENTIA. 

§  1.  Defect  and  Excess  of  Formation. — The  testes  are  absent  when 
the  entire  sexual  apparatus  is  absent ;  sometimes  they  are  wanting  when 
the  other  parts  are  defectively  developed,  or  are  represented  by  a  few 
coils  of  a  seminal  duct :  lastly  they  may  be  in  existence,  but  of  small 
size,  and  incapable  of  further  growth.  In  this  case  the  epididymis  is 
particularly  small,  its  ligament  elongated,  and  the  entire  organ  apparently 
broken  up.  This  is  very  commonly  the  case  when  the  testes  remain  in 
the  abdominal  cavity  or  in  the  inguinal  canal,  and  there  is  an  apparent 
absence  of  testicles  (cryptorchis). 

The  vas  deferens  may  present  a  malformation,  and  after  diminishing 
gradually,  terminate  blindly  at  some  distance  from  the  vesiculge  seminales 
and  generally  in  the  inguinal  canal. 

Excess  of  development,  in  the  shape  of  a  plurality  of  testicles,  is  un- 
doubtedly very  rare  :  the  fact  itself  is  not  supported  by  sufficient  proofs. 

§  2.  Deviations  of  Size. — Increase  of  size  of  the  testicles  depends  upon 
hypersemia,  upon  inflammation  and  its  consequences,  i.  e.  upon  the  in- 
flammatory enlargement  itself,  and  the  residuary  product  of  inflamma- 
tion and  induration  upon  hypertrophy  of  the  cellulo-fibrous  stroma,  and 
upon  morbid  growths  and  degenerations  of  the  organ. 

Enlargements  of  the  testicle  are  to  be  carefully  distinguished  from  dis- 
tension of  the  tunica  vaginalis. 

Besides  congenital  smallness  of  the  testicle,  dependent  upon  arrest  of 
development,  we  not  unfrequently  meet  with  atrophy  of  the  testicle.  It 


AND    VASA    DEFERENTIA.  193 

occurs  not  only  in  the  shape  of  marasmus  senilis,  accompanied  by  flabby 
texture  of  the  organ  and  a  dirty  yellow  color  of  its  tissue,  but  is  found 
at  earlier  periods  of  life  as  a  consequence  of  exhaustion,  of  gonorrhceal 
neuralgia  of  the  testis,  and  from  unexplained  influences  in  the  tropics 
(Larry).  The  testicle  also  becomes  atrophied  in  consequence  of  pressure 
exerted  by  effusion  in  the  vaginal  sac,  by  large  hernise,  by  exudations 
within  its  substance,  and  by  morbid  growths. 

§  3.  Deviations  of  Position. — We  have  to  notice  the  foetal  position  of 
the  testicles  within  the  abdominal  cavity,  or  in  the  inguinal  canal  (crypt- 
orchis).  It  is  important  both  from  being  commonly  associated  with  de- 
fective development  of  the  testicle,  and  on  account  of  the  doubt  arising 
as  to  the  sex  of  the  individual,  as  well  as  on  account  of  the  descent  of 
the  testicle,  which  commonly  occurs  about  the  period  of  puberty,  and  the 
consequent  occurrence  of  (congenital)  inguinal  hernia. 

In  rare  cases  the  descending  testicle  does  not  pursue  its  regular  course  ; 
it  either  passes  under  the  crural  arch,  or  sinks  into  the  pelvic  cavity. 

§  4.  Diseases  of  the  Tissues. 

1.  Inflammation. — a.  Inflammation  of  the  testicle  is  a  common  occur- 
rence ;  but  nevertheless,  rarely  a  subject  of  cadaveric  investigation.     It 
may  be  either  primary,  secondary,  or  metastatic. 

It  may  also  be  acute,  or,  as  is  more  frequently  the  case,  chronic  ;  it 
either  attacks  the  entire  testicle,  or  the  epididymis,  or  single  lobules  of  the 
former  chiefly.  Accordingly,  the  tumefaction  of  the  organ  is  either  uni- 
form or  irregular ;  its  tissue  is  at  first  more  or  less  reddened,  injected, 
and  according  to  the  coagulability  of  the  inflammatory  product,  either 
firmer  or  looser  than  in  the  normal  condition. 

Acute  inflammation  not  unfrequently  passes  into  suppuration  ;  the 
chronic  form  more  frequently  ends  in  induration  and  permanent  enlarge- 
ment of  the  organ.  The  orchitic  abscess  not  unfrequently  discharges  ex- 
ternally by  one  or  more  openings,  after  inducing  perforation  of  the  tunica 
albuginea,  and  of  the  agglutinated  lamellae  of  the  tunica  vaginalis.  The 
inflammatory  product  becomes  more  or  less  organized,  and  converted 
into  a  fibroid  cartilaginous  mass,  and  the  resulting  induration  induces 
atrophy  of  the  testicle. 

b.  Chronic  inflammation  affecting  the  tunica  albuginea,  and  its  pro- 
cesses, in  rare  cases  induces  considerable  thickening  of  this  fibrous  sheath, 
hypertrophy  of  the  fibro-cellular  tissue  within  the  testicle,  enlargement 
and  morbid  induration  of  the  latter,  and  finally  atrophy  of  its  proper 
tissue. 

The  progress  of  inflammations  of  the  testicle  would  appear  to  be  some- 
times impeded,  and  a  cure  brought  on,  by  the  pressure  which  an  effusion 
into  the  tunica  vaginalis  exerts. 

2.  Morbid  groivths. — a.  We  have  already  found  that  fibroid  tissue 
occurs  as  a  consequence  of  chronic  inflammation,  and  its  termination  in 
induration. 

b.  The  formation  of  cysts  is  very  unusual,  a  fact  that  acquires  special 
interest  from  the  frequency  of  their  occurrence  in  the  ovaries. 

c.  Enchondroma  is  equally  rare. 

VOL.  II.  13 


194  ABNORMITIES    OF    THE 

d.  An  anomalous  osseous  substance  is  sometimes  developed  in  the  in- 
durated testicle,  i.  e.  in  the  fibroid  tissue ;  and  assumes  the  shape  of  round, 
tuberculated,  or  tendiniform  concretions. 

e.  Tubercle. — Tubercle  not  unfrequently  attacks  the  testicle  primarily, 
and  its  chief  seat  is  the  epididymis.     From  this  point  it  not  only  spreads 
to  the  vasa  deferentia,  the  vesiculae  seminales,  the  prostate,  and  the 
glands  that  are  connected  with  the  organs  of  generation  generally ;  but 
also  to  the  lymphatics  of  the  abdomen,  the  thorax,  and  even  of  the  neck, 
on  the  one  hand,  or  on  the  other  to  the  urinary  organs,  in  the  manner  pre- 
viously described  (p.  161).     In  the  former  case  we  find  the  glands  ag- 
gregated or  strung  together  in  large,  shapeless,  nodulated  masses,  and 
infiltrated  with  cheesy  tubercular  matter. 

Tubercle  is  developed  in  young  subjects  who  are  predisposed  to  tuber- 
cular affections,  in  consequence  of  excessive  or  unnatural  gratification  of 
the  sexual  desires.  The  pathological  anatomist  has  been  unable  to  de- 
monstrate its  connection  with  gonorrhoea,  or.  in  other  words,  to  prove  the 
blennorrhoic  character  of  the  general  morbid  affection,  as  well  as  of 
tubercle  itself;  and  we,  therefore,  consider  the  gonorrhoeal  theory  of 
orchitic  tubercle  to  be  wanting  in  a  most  essential  point. 

The  affection  proves  fatal,  either  by  the  universal  atrophy  induced  by 
the  effusion  of  tubercle  throughout  the  lymphatic  system,  or  by  the  su- 
pervention of  more  or  less  acute  tubercular  deposition  in  the  urinary 
organs,  in  the  lungs,  on  the  peritoneum,  and  in  the  spleen. 

Orchitic  tubercle  generally  appears  in  the  shape  of  rounded  nodules, 
of  the  size  of  a  millet-  or  hemp-seed,  or  a  pea,  which  coalesce  into 
larger  masses ;  they  scarcely  ever  undergo  a  retrograde  metamor- 
phosis, but  fuse,  and  thus  establish  tubercular  suppuration  or  phthisis 
orchitica.  The  increase  in  size  of  the  testicle  varies  according  to  the 
number  of  the  individual  tubercles,  and  more  still  according  to  the  size  of 
the  tubercular  conglomerations.  Its  surface  is  irregular  and  nodulated. 
The  tissue  surrounding  the  tubercle  and  the  tubercular  abscess  becomes 
cartilaginous,  lardaceous,  and  tough. 

In  the  same  manner  as  elsewhere,  and  especially  in  the  lungs,  we  find 
inflammation  of  the  serous  investment  supervening  upon  tubercular  af- 
fections ;  thus  the  tunica  vaginalis  testis  is  liable  to  attacks  of  inflamma- 
tion, accompanied  by  tuberculizing  exudation  of  various  forms. 

Tubercle  of  the  testicle  is  of  extreme  interest  as  contrasted  with  the 
immunity  from  tubercle  enjoyed  by  the  ovary. 

/.  Cancer. — All  the  varieties  of  cancer  undoubtedly  occur  in  the  tes- 
ticle, but  both  according  to  my  own  observations  and  those  of  others, 
medullary  carcinoma  is  the  most  frequent.  It  always  gives  rise  to  very 
extensive  degeneration,  is  very  soft,  and  presents  fluctuation  ;  sometimes 
it  perforates  the  tunica  vaginalis  and  the  skin,  and  is  thus  converted  into 
an  open  cancerous  sore. 

It  generally  so  completely  takes  the  place  of  the  proper  orchitic  tissue 
that  no  trace  of  the  latter  is  left ;  still  many  cases  occur  in  which  it  oc- 
cupies the  interstices  of  the  hypertrophied  fibro-cellular  stroma  of  the 
testicle.  It  is  peculiarly  liable  to  a  complication  with  renal  cancer,  and 
also  with  medullary  growths  in  the  cellular  tissue  surrounding  the  pelvis 
and  the  hip-joint,  with  medullary  retro-peritoneal  growths,  and  finally 
with  universal  cancerous  cachexia. 


VESICUL^E    SEMINALES.  195 

The  frequency  of  its  occurrence  in  the  testicle,  especially  as  a  primary 
affection,  is  of  interest  when  contrasted  with  the  rarity  of  its  appearance 
in  the  ovary,  and  with  the  frequency  of  cysts  and  the  allied  form  of  areolar 
cancer,  in  the  latter. 

The  vas  deferens  is  generally  attacked  by  disease  extending  to  it  from 
the  testicle,  or  the  vesiculse  seminales  ;  it  is  found  to  be  affected  by  in- 
duration and  thickening  of  its  coats  and  ossification,  which  probably  re- 
sult from  inflammation,  by  tubercle,  and  cancerous  degeneration. 

Appendix. — Abnormities  of  the  Tunica  Vaginalis  Testis. 

In  consequence  of  an  arrest  of  development,  the  cavity  of  the  tunica 
vaginalis  may  remain  in  communication  with  the  peritoneal  cavity,  and 
thus  give  rise  to  congenital  inguinal  hernia. 

All  the  diseases  affecting  the  tissue  of  serous  membranes  are  found  to 
occur  here ;  inflammatory  affections  of  every  degree  and  variety,  followed 
by  the  most  various  effusions,  are  common ;  and  of  the  sequelae,  adhesion 
by  means  of  various  tissues  of  new  formation,  and  ossification  of  the 
fibroid  exudations,  are  not  unfrequent.  Among  the  morbid  growths  we 
notice  the  anomalous  fibroid  and  osseous  tissues  in  the  form  just  mentioned, 
as  well  as  subserous,  fibro-cartilagmous,  and  osteoid  formations,  which 
we  sometimes  find  as  free  corpuscles  in  the  tunica  vaginalis,  and  tubercle, 
occurring  especially  as  tubercular  exudation ;  this  must  be  distinguished 
from  tuberculosis  of  the  testicle,  with  which,  however,  it  is  often  coinci- 
dent. 

Dropsy  of  the  tunica  vaginalis,  or  hydrocele,  is  a  common  disease,  oc- 
casionally brought  on  by  varicosity  and  stasis  in  the  venous  network  of 
the  testicle  and  the  spermatic  cord,  in  which  case  it  has  the  character  of 
a  passive  accumulation ;  sometimes  it  is  the  result  of  slight  inflammatory 
affections  of  the  serous  membrane. 


SECT.    II. — ABNORMITIES   OF   THE   VESICULJS   SEMINALES. 

§  1.  Arrest  and  ^Excess  of  Development. — The  vesiculae  seminales  are 
absent  when  the  testicles  are  deficient,  and  are  more  or  less  abortive  when 
the  testicles  are  imperfectly  developed. 

It  is  stated  that  they  have  been  found  increased  in  number  in  cases  in 
which  there  were  supernumerary  testicles. 

§  2.  Deviations  of  size.  Of  calibre. — Under  this  head  we  class,  on 
the  one  hand,  the  dilatations  of  the  vesiculse  seminales  and  ductus  ejacu- 
latorii,  resulting  from  continued  catarrhal  irritation,  which,  according  to 
Lallemand,  accompanies  spontaneous  discharges  of  semen,  and  on  the 
other,  the  atrophy  and  obliteration  of  the  vesiculae  seminales,  which  may, 
but  does  not  necessarily,  follow  removal  or  atrophy  of  the  testicle. 

§  3.  Diseases  of  the  Tissues. 

1.  Inflammation. — We  not  unfrequently  have  opportunities  of  observ- 
ing, in  the  dead  subject,  the  effects  of  chronic  catarrh  and  its  sequelae, 


196  ABNORMITIES    OF 

upon  the  vesiculae  seminales ;  they  are,  especially,  tumefaction  and  re- 
laxation of  their  mucous  membrane ;  secretion  of  a  grayish  or  yellow 
purulent  mucus  (blennorrhoea),  dilatation,  and,  finally,  thickening  of  the 
parietes.  In  rare  cases  we  find  those  portions  of  the  inner  surface  in 
which  the  mucous  membrane  has  been  destroyed  by  suppuration,  covered 
by  a  whitish  or  slate-colored,  reticular  pulp,  of  a  cellulo-fibrous  texture, 
the  parietes  considerably  thickened  and  cartilaginous,  and  the  cavity 
contracted  and  obliterated.  This  inflammation  as  rarely  degenerates 
into  ulcerative  perforation  of  the  vesiculae  seminales,  the  formation  of 
abscesses  in  their  cellulo-fibrous  nidus,  into  destruction  of  a  neighboring 
coil,  or  communication  of  two  contiguous  tubuli. 

Chronic  catarrh  occurs  chiefly  in  advanced  age,  accompanying  mechani- 
cal hypersemia  of  the  pelvic  veins,  stasis,  varicosity,  and  the  formation 
of  phlebolithes ;  as  a  consequence  of  chronic  vesical  catarrh,  as  a  result 
of  repeated  gonorrhoeal  catarrh  of  the  urethra  and  the  neck  of  the  blad- 
der, of  excessive  venery,  and  especially  of  masturbation. 

2.  We  find  a  low  state  of  irritation  developed  in  a  similar  manner  in 
the  cellulo-fibrous  substratum  of  the  vesiculse  seminales  ;  this  induces  con- 
densation and  hypertrophy  in  the  latter,  and  causes  its  adhesion  to  the 
vesiculge  seminales,  which  thus  become  fixed. 

§  4.  Morbid  Growths. 

1.  Bony  matter  is  sometimes  deposited  in  the  indurated  coats  of  the 
vesiculse  seminales,  as  well  as  in  the  terminal  portion  of  the  vas  deferens 
(ossification).  x 

2.  Tubercle. — Tuberculosis  of  the  mucous  membrane  of  the  vesiculse 
seminales  is  not  an  unfrequent  disease.     When  seen  in  the  dead  subject, 
the  disease  has  generally  attained  such  a  degree  that  the  mucous  mem- 
brane appears  converted  into  a  thick,  yellow,  cheesy,  lardaceous,  fissured, 
purulent  layer  of  tubercular  matter,  filling  up  and  closing  the  passage  of 
the  seminal  vesicles,  whilst  the  superficial  layer  of  their  coats  is  conside- 
rably thickened,  and  infiltrated  with  a  lardaceous  substance.     The  exter- 
nal investment  occasionally  becomes  the  seat  of  tubercular  deposit,  and, 
as  this  fuses,  suppuration  and  perforation  of  the  seminal  vesicles  are  in- 
duced. 

Tubercular  disease  is  associated  with  tubercle  of  the  prostate,  the  tes- 
ticle, and  the  lymphatic  glands  that  belong  to  the  sexual  apparatus,  as 
well  as  with  tubercle  of  the  uropoietic  system.  It  prevails  during  the 
prime  of  life,  and  appears  never  to  occur  before  puberty ;  in  this  it  differs 
essentially  from  tubercular  disease  of  the  uterus  and  the  Fallopian  tubes. 

3.  Cancer   affects   the   vesiculse   seminales   only  by  extension  from 
neighboring  organs. 

§  5.  Anomalies  of  the  Contents  of  the  Vesiculce  Seminales. — The 
seminal  fluid  may  present  various  irregularities ;  it  is  found  mixed  with 
a  greater  or  less  quantity  of  colorless,  vitreous,  grayish,  yellow,  puriform 
mucus,  and  with  pus  ;  if  the  inner  surface  of  the  vesiculse  seminales  has 
undergone  any  change  of  texture  there  may  be  hemorrhagic  exudation, 
tubercular  pus,  cancerous  sanies,  and,  lastly,  calculous  concretions.  The 
pus  and  sanies  may,  as  in  the  ductus  ejaculatorii,  be  introduced  from 


THE    PROSTATE.  197 

neighboring  abscesses,  especially  of  the  prostate,  after  perforation  has 
taken  place. 

SECT.    III. — ABNORMITIES    OF   THE    PROSTATE. 

The  prostate  is  generally  found  to  be  small  when  the  organs  of  gene- 
ration are  in  an  imperfect  condition.  Its  most  important  anomalies  con- 
sist in : — 

§  1.  Abnormities  of  Size. — And  of  these  the  most  common  is  enlarge- 
ment, resulting  from  hypertrophy.  It  is  one  of  the  most  frequent  causes 
of  the  urinary  obstructions  occurring  in  advanced  life.  The  substance 
of  the  gland  in  these  cases  appears  normal,  occasionally  a  little  softened, 
of  a  spongy  elastic  consistency,  and  succulent,  i.  e.  its  ducts  contain  much 
secretion ;  in  other  cases  it  appears  tough  and  coriaceous,  without  visible 
alteration  of  structure.  The  formation  of  fibroid  tumors  (vide  p.  198)  is 
often  complicated  with  this  benignant  variety  of  enlargement. 

The  enlargement  varies  much  in  degree ;  occasionally  it  is  so  consider- 
able that  the  gland  attains  the  size  of  a  fist.  The  lateral  lobes  are  the 
chief  seat  of  the  enlargement,  which  affects  both  uniformly,  or  predomi- 
nates on  one  side  ;  but  the  development  of  a  so-called  middle  lobe  (Home) 
is  of  greater  importance,  in  reference  to  the  impediment  it  offers  to  the 
discharge  of  the  urine  ;  it  not  unfrequently  predominates  in  a  most  re- 
markable manner,  even  when  the  hypertrophy  affects  the  entire  gland. 
It  rises  from  the  posterior  section  of  the  prostatic  ring,  between  the  two 
lateral  lobes,  and,  according  to  its  size,  projects  more  or  less  into  the 
cavity  of  the  bladder.  It  presents  the  appearance  of  a  rounded  tumor, 
of  the  size  of  a  bean,  or  hazel-nut,  which  projects  into  the  neck  of  the 
bladder ;  it  may  increase  to  the  size  of  a  walnut,  hen's  or  duck's  egg,  or 
more,  and  then  protrudes  into  the  cavity  of  the  bladder  in  the  shape  of 
a  smooth  or  rough,  nodulated,  slightly  lobular,  rounded  or  cqrdiform, 
pyramidal  or  cylindrical  tumor. 

All  enlargements  of  the  prostate  impose  an  obstacle  to  the  passage  of 
the  urine,  both  by  narrowing  the  neck  of  the  bladder  and  the  prostatic 
portion  of  the  urethra,  as  well  as  by  inducing  a  change  in  the  direction 
of  the  channel,  by  diminishing  its  calibre,  and  by  dividing  it.  The  last 
two  malformations  are  more  particularly  the  result  of  unilateral  develop- 
ment of  the  gland,  and  of  increase  of  its  middle  lobe.  The  former  not 
only  produces  a  lateral  contraction  and  deformity  of  the  canal  in  the 
vertical  direction,  so  as  to  produce  a  sickle-shaped  fissure,  but  forces  it 
out  of  the  mesial  line  to  the  opposite  side ;  the  middle  lobe  not  only 
obstructs  the  internal  orifice  of  the  urethra,  but  often  narrows  the  neck 
of  the  bladder  by  pushing  it  on  one  side,  or  divides  it  into  two  diverging 
passages,  which  reunite  in  the  prostatic  portion  of  the  urethra. 

The  results  of  this  enlargement  are  hypertrophy  of  the  bladder,  dilata- 
tion of  the  urinary  passages,  &c. 

A  diminution  of  the  prostate,  with  relaxation  of  the  glandular  tissue, 
is  observed  in  rare  cases,  as  accompanying  atrophy  of  the  testicles. 

§  2.  Diseases  of  Tissue. 

1.  Inflammation. — An  opportunity  is  scarcely  ever  presented  of  study- 


198  ABNORMITIES    OF 

ing  inflammation  of  the  prostate  in  the  dead  subject,  except  in  its  results, 
suppuration  and  abscess,  or  induration.  The  former  occurs  not  unfre- 
quently  as  the  issue  of  chronic  inflammation,  which  exacerbates  from 
time  to  time.  The  abscesses,  which  vary  in  size  and  number,  generally 
discharge  themselves  into  the  bladder,  into  the  prostatic  portion  of  the 
urethra,  in  which  case  the  ejaculatory  ducts  are  destroyed,  into  the  vesi- 
culse  seminales,  the  surrounding  cellular  tissue,  or  the  rectum ;  or  they 
force  their  way  along  the  urethra  to  the  penis,  or  into  the  scrotum. 

2.  Morbid  growths. — a.  We  have  never  observed  the  formation  of  cysts 
in  the  prostate. 

5.  Fibroid  tumors  occur  frequently,  and  generally  induce  considerable 
hypertrophy  of  the  gland.  They  are  commonly  of  the  size  of  a  pea,  a 
bean,  or  a  hazel-nut,  round  or  oval,  and  when  deposited  in  the  peripheral 
layer  of  the  gland,  give  rise  to  nodulated  protuberances.  Although  they 
do  not  attain  an  extraordinary  magnitude,  they  are  of  interest,  on  account 
of  the  relation  they  bear  to  analogous  growths  in  the  uterus. 

c.  Tubercle. — Tubercle  of  the  prostate  is  always  complicated  with 
tubercle  of  the  testis,  of  the  vesiculae  seminales,  and  of  the  allied  lym- 
phatic glands.     The  softening  process  gives  rise  to  tubercular  abscesses, 
which  are  enlarged  by  the  fusion  of  secondary  tubercular  deposits  and 
thus  extend  beyond  the  gland,  causing  the  devastations  spoken  of  under 
the  head  of  abscess. 

d.  Cancer. — Cancer  in  any  shape  rarely  occurs  in  the  prostate,  which 
is  curious  as  contrasted  with  the  frequency  of  its  occurrence  in  the  uterus. 
Medullary  carcinoma  is  occasionally  found  to  attack  the  prostate,  and 
to  give  rise  to  considerable  enlargement  of  the  gland ;  it  may  sometimes 
perforate  the  fundus  vesicae,  and  sprout  into  its  cavity,  causing  a  cancer- 
ous ulcer  with  raised  edges,  and  of  varying  size. 

3.  Anomalous  contents  of  the  prostatic  ducts. — The  prostatic  ducts,  in 
advanced  age,  very  often  contain  calculous  concretions ;  they  are  gene- 
rally very  minute,  resembling  fine  sand  or  poppy-seeds,  rarely  attain  the 
size  of  millet-seeds,  and  still  less  frequently  form  conglomerations  of  the 
size  of  hemp-seeds  or  peas.     They  present  a  black,  blackish-brown,  or 
yellowish-brown  color,  are  very  hard,  and  generally  glossy.     Their  num- 
ber varies,  but  is  often  considerable,  and  a  section  of  the  gland  shows 
them  more  or  less  uniformly  scattered  through  its  tissue.     The  gland  at 
the  same  time  appears  very  juicy,  and  the  ducts  are  more  or  less  dilated. 


SECT.   IV. — ABNORMITIES   OF    THE    PENIS. 

§  1.  Defect  and  Uxcess  of  Formation. — The  penis  may  be  smaller  than 
usual,  whilst  the  remainder  of  the  sexual  organs  are  normal,  or  them- 
selves imperfectly  developed,  or  it  may  present  some  further  anomalies 
depending  upon  an  arrest  of  development ;  in  the  latter  case  it  is  reduced 
in  length,  as  is  the  case  in  hypospadiasis  and  hermaphrodisia ;  the  penis 
then  bears  a  resemblance  to  the  clitoris. 

Fissures  of  the  penis,  or  rather  of  the  urethra,  which  sometimes  extend 
to  the  glans,  and  to  the  penis  itself,  are  important.  They  are  termed 
hypospadiasis  and  epispadiasis,  the  former  of  which  is  by  far  the  most 


THE    PENIS.  199 

common.  Both  present  various  degrees,  but  the  first  is  particularly  liable 
to  variations.  We  here  find  the  fissure  affecting  a  greater  or  less  extent 
of  the  urethra  from  the  glans  backwards,  or  even  involving  the  entire 
penis  together  with  the  scrotum }  the  penis  remains  in  a  corresponding 
state  of  imperfect  development  as  to  size  and  form ;  the  prepuce  is  also 
fissured  and  small,  the  glans  divided ;  in  higher  degrees,  the  smallness 
of  the  organ,  the  total  absence  of  foreskin,  the  retraction  of  the  scrotal 
fissure,  and  the  imperforate  condition,  induce  a  resemblance  to  the  cli- 
toris ;  and  mistake  as  to  the  sex  of  the  individual  will  be  the  more  likely 
to  occur  if  the  scrotal  fissure  leads  to  a  cul-de-sac  simulating  the  vaginal 
passage.  Epispadiasis  is  a  very  unusual  occurrence,  and  is  either  limited 
to  the  glans  or  extends  over  the  entire  urethra ;  in  the  latter  case  it  is 
complicated  with  eversion  of  the  bladder  (fissure  of  bladder). 

Excess  of  development,  except  as  more  or  less  remarkable  enlargement 
of  the  penis,  is  very  rare  ;  the  few  observations  recorded  of  two  perfect 
penes  placed  beside  or  above  one  another  are  not  to  be  credited. 

§  2.  Deviations  of  Size. — Atrophy  of  the  penis,  accompanied  by  obli- 
teration of  the  tissue  of  the  glans  and  the  corpora  cavernosa,  deserves 
notice ;  it  is  probably  always  associated  with  atrophy  of  the  testicles. 

An  apparent  diminution  of  the  penis  is  presented  in  the  retracted  state, 
induced  by  large  scrotal  hernise,  sarcocele,  hydrocele,  oedema  of  the  scro- 
tum, &c.,  in  consequence  of  the  relaxation  and  advance  of  the  common 
integument. 

§  3.  Diseases  of  the  Tissues. — They  affect  the  glans  and  the  corpora 
cavernosa  of  the  penis. 

We  meet  with  mechanical  hyperaemia  of  all  the  spongy  tissues  as  an 
accompaniment  of  most  of  the  advanced  stages  of  organic  heart  diseases ; 
we  find  a  similar  tumefaction  of  these  parts  in  cases  of  asphyxia,  espe- 
cially when  produced  by  strangulation. 

Inflammation  of  the  cutaneous  investment  of  the  glans,  which  is  gene- 
rally complicated  with  inflammation  of  the  internal  lamina  of  the  fore- 
skin, gives  rise  to  excoriation,  exudation  of  coagulable  lymph,  adhesion 
of  the  prepuce  to  the  glans,  suppuration,  and  ulceration ;  when  chronic, 
it  induces  exuberant  formation  of  epidermis,  and  if  the  deeper  parts  of 
the  parenchyma  of  the  glans  are  involved,  obliteration,  cartilaginous 
induration,  and  atrophy  follow.  Inflammation  of  the  coronal  follicles  in- 
duces increased  secretion  of  a  fluid,  corroding  smegma,  and  follicular  ul- 
ceration. Ulcers  of  a  specific  character  present  deep,  white,  striated,  more 
or  less  hard,  cartilaginous  cicatrices,  which  vary  according  to  the  size  of 
the  ulcerated  surface,  and  the  intensity  of  the  surrounding  reaction. 

Inflammation  of  the  corpora  cavernosa,  though  of  rare  occurrence,  is 
brought  on  by  contusions  or  by  gonorrhoeal  metastases  ;  it  occasionally 
terminates  in  obliteration  of  the  cells,  and,  by  means  of  the  inflammatory 
product,  in  the  conversion  of  the  latter  into  a  cellulo-fibrous  cicatrix ; 
the  uniform  turgescence  of  the  penis  in  erection  is  thus  permanently 
impeded. 

Among  the  morbid  growths,  we  have  to  notice  the  warts  occurring  on 
the  glans,  and  carcinoma,  and  carcinomatous  ulcers  on  the  glans  and  the 


200  ABNORMITIES    OF 

corpora  cavernosa ;  the  former  occur  frequently,  the  latter  very  rarely. 
Cancer  appears  chiefly  to  assume  the  medullary  form ;  it  gives  rise  to 
considerable  malformation  and  enlargement,  and  to  ulcerative  destruction 
of  the  penis. 

We  find  an  anomaly  in  the  secretion  occurring  in  the  shape  of  abun- 
dant discharge  of  sebaceous  matter,  which,  in  the  case  of  phimosis  or  a 
neglect  of  cleanliness,  accumulates  on  the  glans  and  round  the  corona  in 
the  shape  of  lamellae  and  tubercular  masses,  and,  after  long  stagnation 
and  decomposition,  brings  on  inflammation,  excoriation,  and  ulceration, 
or  becomes  inspissated,  so  as  to  form  calculous  concretions  (calculi  glandis). 

SECT.   V. — ABNORMITIES   OF   THE   CUTANEOUS   COVERING   OF   THE 
PENIS   AND   THE   SCROTUM. 

§  1.  Defect  and  Excess  of  Formation. — As  a  defect  of  formation,  we 
notice  the  occurrence  of  extreme  shortness  or  contraction  (phimosis)  of 
the  prepuce;  fissure  and  entire  absence  of  the  foreskin  in  hypospadiasis, 
and  the  clitoroid  arrest  of  development  of  the  penis.  The  scrotum  is  small 
when  the  sexual  apparatus  is  imperfectly  developed,  and  in  cryptorchis, 
and  is  sometimes  only  represented  by  a  slighthly  corrugated  cutaneous 
fold,  which  shows  an  almost  imperceptible  raphe,  and  occasionally  con- 
tains adipose  cellular  tissue.  In  hermaphroditic  formations  it  is  fissured 
and  resembles  the  labia  of  the  female  genitals,  in  those  cases  especially 
in  which  the  two  halves  are  empty,  viz.,  when  the  testicles  have  been 
retained  in  the  abdomen  or  in  the  inguinal  canals. 

Excess  of  development  occurs  in  the  penis  in  the  shape  of  exuberant 
formation  of  skin,  as  a  very  long  foreskin  (occasionally  characteristic  of 
a  particular  race),  in  the  scrotum  as  considerable  enlargement,  and  in 
either  as  extreme  thickness  of  the  common  integument,  with  an  unusually 
well-marked  and  projecting  raphe,  which  is  continued  upwards  on  the 
penis;  there  is  also  an  accumulation  of  the  tissue  of  the  tunica  dartos 
and  of  the  subcutaneous  cellular  tissue. 

§  2.  Anomalies  of  Size. — Besides  the  congenital  anomalies  we  have  to 
notice  the  acquired  enlargement  of  the  scrotum  resulting  from  hyper- 
trophy of  the  tunica  dartos,  sarcocele,  or  elephantiasis,  accompanied 
by  fibrous  induration ;  in  Egypt  more  especially  it  attains  the  most 
enormous  dimensions. 

§  3.  Diseases  of  the  Tissues. — The  common  integument  of  these  parts 
is  liable  to  the  primary  and  secondary  diseases  to  which  the  skin  gene- 
rally is  subject ;  but  it  is  also  liable  to  primary  and  secondary  inflam- 
matory process  of  a  specific  character,  to  ulcerative  disorganization,  to 
induration  and  condensation,  and  even  to  gangrenous  destruction. 
Paraphimosis  of  the  prepuce  resulting  from  inflammatory  swelling,  and 
the  ulceration  which  causes  the  glans  to  pass  through  the  ulcerated  open- 
ing, and  denudes  the  glans  of  its  foreskin,  deserve  special  mention. 
The  scrotum  is  frequently  attacked  by  metastatic  processes  and  by  gan- 
grene ;  it  is  remarkable  for  the  facility  with  which  it  is  reproduced ;  it  is 
also  subject  to  leprous  degeneration,  discoloration,  and  to  chimney- 


THE    VAGINA.  201 

sweeper's  cancer.  The  tunica  dartos  is  variously  affected  in  the  above- 
mentioned  processes ;  it  is  also  found  to  be  the  seat  of  oedema,  of  san- 
guineous effusion  (haematocele),  of  urinary  infiltration,  suppurative  in- 
flammation, fibrous  induration,  which  is  sometimes  confined  to  the  sep- 
tum scroti,  of  urinary  fistulas,  and  of  various  morbid  growths. 


CHAPTER  III. 

ABNORMITIES  OF  THE  FEMALE  SEXUAL  ORGANS. 

THE  EXTERNAL  GENITALS. 
SECT.   I. — ABNORMITIES   OF  THE   PUDENDA. 

ARREST  of  development  occurs  in  the  shape  of  total  absence  of  the 
pudenda  ;  absence  or  defective  development,  i.  e.  unusual  smallness  of 
individual  parts,  the  labia  majora  andminora,  or  the  clitoris;  absence  of 
the  rima  or  of  the  commissures,  i.  e.  unusual  fissures,  such  as  we  see  at 
the  superior  commissure,  accompanied  by  eversion  of  the  bladder  and 
separation  of  the  symphysis  pubis. 

Excess  of  development  is  met  with  as  uniform  or  partial  congenital 
enlargement  of  the  labia,  nymphae,  and  clitoris,  causing  the  latter  to  re- 
semble a  penis ;  as  increase  in  the  number  of  individual  parts,  as  of  the 
nymphae,  and  as  precocious  or  extravagant  development  during  puberty. 

Congenital  anomalies  of  form  affect  particularly  the  nymphae  ;  like  the 
acquired  anomalies,  they  present  several  varieties. 

The  diseases  of  tissue  are  primary  or  secondary ;  they  consist  in  me- 
tastatic  inflammatory  processes,  varying  in  degree  and  rapidity,  accom- 
panied by  increased  sebaceous  secretion,  great  epidermal  development, 
excoriation,  oedema,  superficial  and  profound  suppuration,  condensation 
and  induration,  gangrene  of  the  external  and  internal  labia ;  we  meet 
with  specific  circumscribed  inflammation  and  ulceration  of  the  latter ; 
among  adventitious  products,  condylomatous  excrescences  occur  in  them 
and  on  the  clitoris,  varying  in  size  and  number,  and  occasionally  pro- 
ducing extreme  deformities.  We  also  find  hemorrhagic  effusion  occur- 
ring within  the  labia  spontaneously,  or  in  consequence  of  external  violence 
(sanguineous  tumors),  and,  besides  steatomatous  (fibroid)  tumors,  all  the 
adventitious  growths  occurring  in  the  cellular  tissue  at  large. 

SECT.    II. — ABNORMITIES   OF   THE  VAGINA. 

§  1.  Defect  and  Excess  of  Formation. — The  vagina  may  be  totally 
absent,  or  partially  deficient ;  in  the  latter  case  there  is  a  cul-de-sac 
opening  externally,  or  the  vagina  terminates  blindly  at  a  greater  or  less 
distance  from  the  labia,  or  opens  posteriorly  into  the  urethra — in  this 
instance  the  development  takes  place  from  both  points,  but  an  intervening 


202  ABNORMITIES    OF 

portion  is  defective,  thus  forming  a  transition  to  congenital  atresia. 
When  the  other  parts  of  the  sexual  apparatus  are  atrophied,  or  certain 
of  its  sections,  as,  for  instance,  the  clitoris,  approach  the  male  type,  or 
in  cases  of  hermaphrodisia  per  excessum,  the  vagina  is  not  duly  developed, 
and  is  found  rather  narrow  than  short,  smooth,  and  without  rugae. 

We  must  here  allude  to  an  apparent  excess  of  development,  called  the 
double  vagina,  or  division  of  the  vagina  into  two  channels  which  lie  in 
juxtaposition  to  one  another.  It  is  produced  by  a  vertical  septum  that 
descends  along  the  mesial  line  of  the  vagina ;  and  in  a  low  degree 
is  indicated  by  a  more  ridge-like  elevation  of  the  columnar  rugae.  The 
division  of  the  vagina  may  be  complete,  and  is  then  associated  with  divi- 
sion of  the  uterus  and  its  orifice,  and  with  a  double  hymen ;  or  it  may  be 
incomplete,  and  in  this  case  the  septum  ceases  above,  and  the  fornix 
vaginae  is  common  to  both  passages,  the  os  tincae  being  at  the  same  time 
single  or  double  ;  or  else  the  septum  does  not  reach  down  to  the  vaginal 
entrance,  which  is  protected  by  a  single  hymen,  and  the  vagina  is  single 
to  a  greater  or  less  extent ;  or,  lastly,  the  septum  is  incomplete,  inasmuch 
as  it  presents  partial  defects.  The  deviation  of  the  septum  from  the 
mesial  line,  which  occurs  in  rare  cases,  is  of  interest  and  importance  ; 
the  passage  on  one  side  may  then  be  imperfect,  or  have  a  blind  termina- 
tion above  or  below.  The  following  case,  taken  from  our  collection,  is 
an  instance : 

Sexual  organs  of  a  very  imperfectly-developed  female  of  fifteen,  who 
was  covered  with  scrofulous  ulcers  and  cicatrices,  and  died  of  tubercular 
phthisis  of  the  lungs  and  the  intestines.  Two  very  delicate,  elongated, 
fusiform  uteri,  each  provided  with  one  Fallopian  tube  and  one  large  ovary, 
unite  at  the  point  of  the  internal  orifice  at  an  obtuse  angle  (uterus  bi- 
cornis),  and  are  from  this  point  separated  by  a  vertical  septum,  so  that 
each  cervix  has  its  distinct  vagina.  The  two  vaginae  descend  on  both 
sides  of  a  septum,  which  is  a  continuation  of  the  septum  uteri,  down  to 
the  external  pudenda,  which  are  closed  by  a  single  hymen,  the  left  vagina 
being  considerably  wider  and  presenting  larger  rugae  than  the  right.  The 
latter  terminates  at  about  the  middle  of  the  entire  vagina,  in  a  blind  sac 
formed  by  the  septum ;  the  left  vagina  immediately  bulges  out  to  the 
right  in  the  shape  of  a  single  canal.  The  external  organs  are,  like  the 
uterus,  in  an  extremely  undeveloped  condition.  It  is  a  curious  coinci- 
dence that  the  right  kidney  was  absent,  the  left  being  at  the  same  time 
enlarged,  and  its  hilus  directed  forwards. 

The  hymen  is  often  too  large,  owing  to  excess  of  development,  so  as 
almost  to  close  up  the  entire  passage  ;  it  deviates  at  the  same  time  from 
its  normal  shape  and  mode  of  attachment,  inasmuch  as  it  is  generally 
connected  with  the  internal  labia  by  a  small  round  column,  by  which 
means  two  orifices  are  formed  which  lead  into  the  vagina. 

§  2.  Anomalies  of  Size. — The  congenital  anomalies  involve  a  greater 
or  less  dilatation,  such  as  we  find  to  be  peculiar  to  some  nations  ;  and 
the  contraction  which  we  have  spoken  of  above,  the  highest  degree  of 
which  is  complete  closure. 

Congenital  atresia,  which  we  have  above  classed  with  partial  defect  of 
the  vagina,  is  commonly  produced  by  an  enlarged  hymen,  or,  in  excep- 


THE    VAGINA.  203 

tional  cases,  by  a  horizontal  or  obliquely  placed  membrane,  which  oc- 
cupies different  parts  of  the  passage ;  if  carefully  examined  we  should 
probably  find  that  it  was  formed  by  the  adherent  parietes  of  a  vagina, 
ending  above  and  below  in  a  cul-de-sac.  This  form  of  atresia  would,  in 
that  case,  have  to  be  considered  as  partial  (and  slight)  deficiency  of  the 
vagina. 

The  acquired  irregularities  appear,  on  the  one  hand,  as  unnatural 
elongation  or  dilatation ;  on  the  other,  as  shortening  or  narrowing, 
amounting  even  to  complete  obturation. 

The  vagina  is  liable  to  a  uniform  or  partial  elongation,  with  disap- 
pearance of  the  rugae  and  diminution  of  its  arch,  in  consequence  of  traction 
exerted  by  the  uterus  or  ovaries,  owing  to  uterine  tumors  or  enlarged 
ovaries  that  mount  into  the  abdomen,  or  to  morbid  growths  that  force 
those  organs  upwards.  Prolapsus  uteri,  tumors  projecting  into  its  cavity, 
especially  fibroid  tumors,  polypi  of  the  uterus,  pessaries,  and  the  like, 
induce  dilatation  of  the  vagina. 

Shortening  or  narrowing  is  the  result  of  injury  and  loss  of  tissue  that 
has  been  intentionally  or  accidentally  induced,  of  ulceration  and  the 
resulting  cicatrices.  The  vagina  is  also  narrowed  when  the  passage  is 
elongated  by  traction,  and  its  cavity  is  diminished  when  the  cervix  uteri 
becomes  atrophied. 

Acquired  atresia  may  be  complete  or  incomplete,  and  result  from  ad- 
hesion of  the  anterior  and  posterior  walls  of  the  vagina  to  a  greater  or 
less  extent,  in  consequence  of  excoriation  or  ulceration ;  or  it  may  be 
produced  by  flat  or  rounded  cords  that  pass  horizontally  or  diagonally 
across  the  vagina  and  reduce  its  calibre.  The  latter  may  consist  of 
vaginal  folds  brought  on  by  traction,  or  of  the  membranous  bands  left 
after  the  cure  of  ulcerative  loss  of  substance. 

§  3.  Deviations  in  Position  and  Form. — The  form  of  the  vagina  is 
modified  in  a  manner' corresponding  to  the  anomalies  which  we  have  first 
examined,  and  in  a  medico-legal  point  of  view  we  have  to  notice  the 
unusual  forms  presented  by  the  hymen  after  it  has  been  ruptured.  In- 
stead of  the  carunculae  myrtiformes,  a  more  or  less  considerable  annular 
tumor  remains  ;  or  if  the  hymen  was  inserted  into  the  nymphse,  one  half 
is  left  so  as  to  form  a  species  of  valve,  or  it  is  entirely  torn  out  in  the 
shape  of  a  ring. 

Among  the  deviations  of  position  we  notice  intussusception  and  pro- 
lapsus of  the  vagina,  which  affect  mainly  the  anterior  wall  of  the  vagina, 
and  the  eversion  of  the  anterior  or  posterior  vaginal  parietes  in  vaginal 
hernia  (cystocele  vaginalis,  hernia  vaginalis  posterior). 

§  4.  Solutions  of  Continuity. — Besides  the  injuries  inflicted  by  means 
of  cutting  instruments,  which  generally  implicate  various  neighboring 
organs,  and  the  ruptures  caused  by  concussion  and  contusion,  we  have 
to  mention  the  contusions  and  ruptures  of  the  vagina  occurring  during 
parturition,  whether  or  not  occasioned  by  operative  interference,  and 
the  loss  of  substance  by  ulceration.  The  contusions  or  lacerations  affect 
the  vagina  alone,  either  superficially  or  throughout  its  tissues,  or  they 
are  associated  with  contusions  and  lacerations  of  the  uterus  ;  in  the  last 


204  ABNORMITIES    OF 

case,  the  injury  affects  the  vagina  and  the  uterus  simultaneously,  or  a 
laceration  of  the  latter  is  carried  down  to  the  former  to  a  greater  or 
smaller  extent.  Neighboring  organs,  and  especially  the  bladder,  may 
also  be  involved  in  the  solution  of  continuity. 

In  difficult  or  hurried  parturition,  when  the  parts  have  not  been  pro- 
perly supported,  the  vagina,  the  posterior  commissure,  and  the  perineum 
may  be  ruptured,  and  when  the  parturition  is  effected  by  the  perineum, 
the  vagina  is  perforated  above  the  sphincter. 

Ulcerative  destruction  is  not  always  limited  to  the  vagina,  but  fre- 
quently gives  rise  to  communications  between  the  cavities  of  the  vagina, 
the  bladder,  or  the  rectum,  or  with  both  at  the  same  time  by  means  of 
fistulas  or  large  cloacae. 

§  5.  Diseases  of  the  Tissues. 

1.  Inflammation. — a.  Catarrh  affects  the  vagina  very  frequently  in 
the  protracted  acute,  or,  if  blennorrhoic,  in  the  chronic  form,  and  pre- 
sents the  most  various  characters.  It  may  be  a  simple  benignant  catarrh^ 
or  have  the  specific  qualities  of  the  scrofulous,  arthritic,  syphilitic,  im- 
petiginous,  or  gonorrhoeal  catarrh ;  it  is  sometimes  complicated  with 
blennorrhoea  of  other  mucous  membranes,  and  is  either  idiopathic  or 
symptomatic,  accompanying  various  local  inflammatory,  ulcerative,  or  de- 
generate processes  in  the  vagina,  the  uterus,  and  neighboring  organs. 

The  vagina  appears  flabby,  its  mucous  membrane  tumefied  and  pale, 
invested  with  a  pale  thick  coating  of  epithelium,  or  excoriated  and  red- 
dened, with  enlargement  of  the  follicles,  which  are  surrounded  by  a  vas- 
cular ring.  It  contains  and  discharges  a  secretion  varying  in  quantity 
and  quality,  and  mixed  up  with  the  products  of  the  associated  inflam- 
matory and  ulcerative  processes.  In  its  pure  condition  it  is  a  white, 
thin,  milky,  or  creamy  mucous,  which  is  commonly  secreted  in  consi- 
derable quantities,  and  indicates  an  abundant  formation  of  epithelium 
and  desquamation,  or  it  appears  as  a  vitreous,  grumous,  and  viscid,  or 
as  a  yellow  puriform  mucus. 

Catarrh  of  the  vagina  is  an  important  disease,  not  only  on  account  of 
the  extreme  loss  of  fluids  which  it  often  entails,  but  also  on  account  of 
the  imminent  danger  of  its  extension  to  the  uterus  and  the  Fallopian 
tubes,  and  the  consequent  morbid  affection  of  these  organs.  It  pre- 
disposes to  intussusception  of  the  vagina,  owing  to  the  relaxation  it 
induces ;  it  leads  to  excoriation  and  superficial  ulceration,  both  of  the 
vagina,  the  external  pudenda,  the  parts  in  their  vicinity,  and  of  the 
cervix  uteri,  to  closure  of  the  os  tincae,  to  follicular  suppuration,  atresia 
vaginae,  permanent  hypertrophy  of  the  follicles,  and  dilatation  of  the 
vaginal  vessels.  It  follows  that  a  cure  is  effected  with  extreme  diffi- 
culty, and  that  relapses  occur  very  frequently. 

b.  Exudative  processes. — In  rare  cases  primary  croup  occurs  on  the 
vaginal  mucous  membrane  alone ;  but  it  exists  more  frequently  in  com- 
plication with  an  exudative  process  on  the  internal  surface  of  the  uterus, 
in  the  shape  of  puerperal  disease.  As  the  latter  generally  predomi- 
nates, the  affection  is  usually  found  to  have  spread  from  the  uterus  to 
the  vagina.  Exudative  processes  with  various  products  occur  more  fre- 
quently in  patches,  or  throughout  the  vagina  as  secondary  diseases,  both 


THE    VAGINA.  205 

a$  a  result  of  puerperal  affection  of  the  uterus,  as  well  as  in  consequence 
of  an  infection  of  the  blood  proceeding  from  other  causes,  or  from  a  de- 
generation of  the  typhous  and  various  exanthematic  processes.  They 
correspond  to  the  condition  of  the  blood  and  its  products,  and  accord- 
ingly produce  a  solution  of  the  mucous  membrane  and  the  submucous 
layer,  varying  in  shape  and  depth,  and  not  unfrequently  resembling 
gangrenous  destruction.  A  loss  of  substance  may  ensue,  and  to  this 
cause  undoubtedly  many  cicatrices  found  in  these  parts  are  to  be  attri- 
buted. They  also  not  unfrequently  extend  to  the  pudenda,  the  peri- 
neum, and  the  nates,  and  give  rise  to  extensive  disorganization. 

We  must  make  special  mention  of  the  secondary  form  of  typhus 
occurring  in  the  vagina.  It  does  not  appear  to  exhibit  itself  in  the 
vaginal  mucous  membrane  in  its  genuine  form,  but  is  often  found  de- 
generated into  croup  and  gangrene.  It  is  remarkable  that  an  existing 
blennorrhcea,  especially  if  of  a  gonorrhoeal  or  syphilitic  character,  exerts 
a  powerful  attraction  upon  it. 

c.  Inflammation  of  the  submucous  cellular  tissue  of  the  vagina. — It 
very  rarely  appears  in  the  chronic  form  ;  it  leads  to  considerable  thick- 
ening and  coriaceous  induration  of  the  vaginal  parietes ;  the  latter  at 
the  same  time  become  less  movable,  so  as  to  seem  agglutinated  to  the 
adjoining  parts. 

2.  Ulcer ative  processes. — We  here  meet  with  the  simple  (catarrhal) 
follicular  ulcer,  the  circumscribed  or  diffused  solution  of  the  tissues  re- 
sulting from  exudative  processes,  the  syphilitic  ulcer,  the  phagedsenic 
ulcer  of  the  os  uteri,  which  generally  spreads  from  the  cervix  uteri  to 
the  vagina,  and  the  true  cancerous  ulcer.     At  the  cervix  we  find  some 
other  ulcers,  of  which  we  shall  have  occasion  to  speak  more  fully  at  a 
future  period. 

3.  G-angrene  of  the  vagina. — Gangrene  is  the  result  of  pressure  and 
contusion  produced  during  difficult  parturition  ;  it  also  occurs  in  the 
shape  of  gangrenous  eschar  and  gangrenous  or  putrid  fusion  of  the 
mucous  and  submucous  layers. 

4.  Morbid  growths. — Their  occurrence  is  altogether  unusual,  and  even 
the  fibrous  and  cancerous  tumors  that  we  meet  with  are  but  rarely  ob- 
served.    The  cysts  that  are  found  in  this  region  are  developed  in  the 
cellular /tissue  external  to  the  vagina,  and,  anatomically  speaking,  bear 
a  very  subordinate  relation  to  the  latter. 

Fibroid  productions  almost  invariably  coexist  with  similar  growths  in 
the  uterus  ;  they  may  be  developed  in  the  external  fibro-cellular  layer 
of  the  vaginal  parietes,  and  especially  at  their  posterior  surface  ;  they 
then  project  with  a  larger  or  smaller  segment,  in  the  shape  of  round 
tumors,  into  the  vaginal  cavity.  In  other  instances  they  are  developed 
in  the  cellular  tissue  that  is  interposed  between  the  vagina  and  the 
rectum,  and,  though  in  close  relation  to  the  vagina  in  point  of  origin, 
project  chiefly  into  the  rectum,  and  more  or  less  obstruct  its  inferior 
portion.  The  latter  circumstances  are  characteristic  of  the  relation  in 
which  these  morbid  growths  stand  to  the  uterus  and  to  the  accumu- 
lations of  cellular  tissue  which  occur  in  these  regions. 

Carcinoma  of  the  vagina  is,  in  most  cases,  cancer  of  the  uterus  which 
has  spread  to  the  vagina  ;  however  it  may  exist,  though  the  latter  is  in 


206  ABNORMITIES    OF 

a  very  undeveloped  state,  and  even  without  it,  in  the  shape  of  primary 
carcinoma  of  the  vagina.  It  belongs  to  the  fibrous  or  medullary  variety, 
and,  in  proportion  to  its  growth,  induces  thickening  of  the  parietes,  tu- 
berculated  condensation  of  the  internal  surface,  and  corresponding  con- 
traction of  the  passage ;  the  vagina  becomes  adherent  to  the  neighboring 
parts,  in  consequence  of  cancerous  degeneration  of  the  cellular  tissue 
surrounding  it  and  the  rectum,  and  finally  cancerous  ulceration  and 
excrescences  are  established.  The  greater  part  of  the  vagina  generally 
becomes  involved,  and  the  lower  portion  is  prolapsed ;  the  disease  ex- 
tends to  the  rectum,  the  bladder,  the  urethra ;  by  the  pressure  it  exerts 
it  causes  retention  of  the  urine  and  dilatation  of  the  bladder,  and,  when 
it  has  reached  the  ulcerative  stage,  recto-  and  vesico-vaginal  fistulse 
result. 

§  6.  Anomalies  of  the  Contents  of  the  Vagina. — Under  this  head  we 
class,  besides  the  anomalies  of  the  mucous  secretion  in  vaginal  catarrh, 
the  products  of  exudative  and  ulcerative  processes,  the  contents  of  the 
bladder  and  the  rectum,  when  introduced  by  fistulous  communications, 
the  products  of  the  diseased  mucous  membrane  of  the  uterus  and  the 
Fallopian  tubes  ;  blood  that  may  be  derived  from  various  sources,  and  in 
various  states  of  coagulation,  discoloration,  and  decomposition.  The 
presence  of  blood  assumes  particular  importance  when  it  is  retained  by 
a  redundant  hymen,  or  by  congenital  or  acquired  obturation  ;  we  include 
in  this  category  pessaries  and  the  adherent  calculous  deposits,  various 
substances  that  have  been  introduced  from  without,  and,  lastly,  the  pro- 
blematic cases  of  vaginal  pregnancy. 


THE  INTERNAL  SEXUAL  ORGANS. 
SECT.    I. — ABNORMITIES   OF  THE   UTERUS. 

§  1.  Defect  and  Excess  of  Formation. — Complete  absence  of  the 
uterus  must  be  considered  as  extremely  rare  ;  in  most  cases  in  which  the 
uterus  was  found  deficient  in  the  dead  or  living  subject,  rudiments  of  a 
uterine  organ  of  different  forms  were  discovered.1 

The  most  common  case  of  arrest,  which  is  generally  considered  as 
absence  of  the  uterus,  is  that  in  which  the  fold  of  the  peritoneum,  which 
is  destined  for  the  reception  of  the  internal  sexual  organs,  contains,  on 
one  or  both  sides,  posteriorly  to  the  bladder,  one  or  two  small,  flattened, 
solid  masses,  or  larger  hollow  bodies,  with  a  cavity  of  the  size  of  a  pea 
or  a  lentil,  which  is  lined  with  mucous  membrane.  They  are  to  be 
viewed  as  rudiments  of  the  uterine  horns,  and  the  Fallopian  tubes  bear 
an  exact  relation  to  their  development.  These  may  either  be  totally  de- 
ficient, or  terminate  in  the  vicinity  of  the  uterus  in  the  peritoneum  as 
blind  ducts,  or  they  may  communicate  with  the  uterus  with  or  without 
an  open  passage. 

1  Oestr.  Jahrb.  xvii.  1. 


THE    UTERUS.  207 

This  formation  of  the  uterus,  and  especially  the  existence  of  two 
lateral,  hollow,  elongated  and  rounded  uterine  rudiments,  each  of  which 
is  connected  with  a  corresponding  Fallopian  tube  and  ovary,  constitutes 
what  Mayer  terms  the  uterus  bipartite.  From  each  of  the  uterine  rudi- 
ments a  flattened,  round  cord  of  uterine  tissue  ascends  within  the  fold  of 
the  peritoneum,  and  the  two  from  each  side  coalesce.  The  place  of  the 
uterus  is  occupied  by  cellular  tissue,  in  which  a  few  uterine  fibres,  de- 
rived from  the  just-mentioned  cord,  may  be  traced;  it  presents  the 
general  outline  of  a  uterus,  and,  reaching  downwards,  rests  upon  the 
arch  of  a  short  vaginal  cul-de-sac.  The  external  sexual  organs  and  the 
mammary  glands,  as  well  as  the  general  sexual  character  of  the  indivi- 
dual, attain  a  normal  development. 

If  we  pursue  the  progress  of  these  uterine  rudiments  we  find  a  de- 
velopment on  one  or  both  sides ;  representing  in  the  former  case,  a 
uterine  half,  or  a  uterus  unicornis ;  in  the  latter,  a  two-horned  uterus,  or 
uterus  bicornis,  varying  in  degree  ;  this  is  what  is  falsely  called  the 
double  uterus,  uterus  duplex.  These,  and  the  following  uterine  forma- 
tions which  depend  upon  fissure,  offer  considerable  interest. 

The  one-horned  uterus  may  be  always  demonstrated  to  be  a  uterine 
half,  developed  from  a  rudimentary  uterine  horn,  or  the  unsymmetrical 
half  of  a  uterus  bicornis,  either  of  the  right  or  the  left  side.  It  is  a 
cylindrical  or  fusiform  body,  that  is  curved  towards  the  corresponding 
side,  and  from  the  superior  portion  of  which  a  tube  passes  to  the  ovary. 
The  following  are  the  proofs  of  its  resulting  from  an  arrest  of  develop- 
ment ;  it  presents : 

Firstly.  A  vertical  diameter,  which  generally  resembles  that  of  a 
normal  uterus ; 

Secondly.  A  diminution  of  the  transverse  diameter  ; 

Thirdly.  A  small  (virginal)  fundus,  with  a  preponderating  thickness  of 
the  long  and  spacious  cervix  (foetal  state) ; 

Fourthly.  The  arch  in  which  this  uterus  is  deflected  from  the  meridian 
is  variously  curved ; 

Fifthly.  The  cervix,  as  it  descends,  corresponds  more  and  more  to  the 
axis  of  the  body,  and  its  vaginal  portion  entirely  coincides  with  it.  In 
the  virginal  uterus  the  latter  is  always  small,  and  the  vagina  narrow ; 

Sixthly.  In  the  os  tincae  the  palmse  plicatae  approach  closer  to  the 
convex  margin  of  the  uterus ; 

Seventhly,  The  broad  ligament  on  the  side  of  the  deficient  uterine 
half  is  in  some  cases  remarkably  large ;  it  at  least  presents  sufficient 
room  for  the  absent  symmetrical  half  of  the  uterus. 

The  Fallopian  tube  of  the  defective  side  shows  various  relations ;  if 
there  is  no  indication  of  a  uterine  horn  it  is  almost  always  absent,  and 
the  broad  ligament  generally  forms  a  slightly  fringed  prolongation  at 
the  point  corresponding  to  the  free  end  of  the  tube.  Occasionally  it  is 
even  absent  when  there  is  a  rudimentary  uterine  horn,  and  it  presents 
the  relations  described  at  p.  206.  In  rare  cases  we  find  a  total  absence 
of  one  half  of  the  uterus,  whilst  the  corresponding  tube  terminates 
blindly  in  the  convex  margin  of  the  one-horned  uterus  above  its  cervix. 

The  ovary  of  the  defective  side  is,  with  rare  exceptions,  present  even 
when  the  Fallopian  tube  is  wanting. 


208  ABNORMITIES    OF 

We  are  the  more  induced  to  extract  the  following  remarkable  case 
from  the  essay  cited  elsewhere  (Vol.  III.)  as  an  instance  of  the  transi- 
tion from  the  uterus  bipartitus  to  the  uterus  bicornis,  as  the  case  of  preg- 
nancy in  a  uterine  rudiment  (one-half  of  the  uterus  bipartitus),  which  we 
shall  have  occasion  to  quote  at  a  future  period,  will  thus  be  rendered 
more  intelligible. 

The  internal  sexual  organs  of  a  tailor's  wife,  set.  34,  who  died  in  the 
lunatic  asylum  on  the  24th  of  September,  1830,  had  always  menstruated 
scantily,  and  bore  no  children,  present  the  following  relations.  The 
uterus  has  a  conical  shape,  is  two  inches  and  three  lines  in  length,  pre- 
sents a  curve  to  the  left,  has  tolerably  thick  parietes,  and  is  acuminated 
above ;  the  fimbriated  extremity  of  the  Fallopian  tube  is  agglutinated  to 
its  ovary.  On  the  right  side  there  is  a  very  large  ligamentum  latum, 
within  which,  at  a  distance  of  two  inches  from  the  uterus  just  described, 
and  on  a  level  with  its  superior  portion,  there  is  a  body  of  the  size  of  a 
hazel-nut,  consisting  of  uterine  tissue,  and  presenting  a  cavity  of  the 
size  of  a  lentil,  into  which  a  tube  an  inch  and  a  half  long,  and  of  a 
sigmoid  serpentine  form,  opens.  Posteriorly  this  uterine  rudiment  sends 
off  a  carneous  prolongation,  representing  the  ovarian  ligament,  anteriorly 
it  gives  off  a  round  ligament.  On  its  inner  side  it  is  prolonged  in  the 
direction  of  its  axis,  i.  e.  obliquely  downwards,  as  a  solid  band  of  uterine 
substance,  which  impinges  upon  the  convex  right  margin  of  the  left 
uterus  one  inch  above  its  external  orifice.  Both  ovaries  are  small  and 
contracted,  the  cervix  is  small,  the  vagina  narrow,  and  its  arch  infundi- 
buliform. 

If  the  two  rudiments  of  the  uterus  bipartitus  are  developed  uniformly, 
according  to  the  type  of  the  one-horned  uterus,  two  uterine  halves  are 
formed,  which  unite  at  one  point  of  their  convexity,  and  thus  give  rise 
to  the  uterus  bicornis.  The  degree  of  this  abnormity  varies,  and  de- 
pends chiefly  upon  the  point  at  which  the  two  halves  coalesce.  The 
nearer  the  latter  approaches  to  the  external  orifice,  the  more  obtuse  will 
be  the  angle  at  which  the  junction  takes  place,  and  consequently  the 
more  extensive  the  fissure.  The  higher  the  point  of  union,  the  more 
acute  will  be  the  angle,  and  it  may  thus  become  so  small  that  the  two 
halves  lie  almost  parallel  to  one  another,  and  there  is  only  a  slight 
divergence  of  the  two  horns.  In  the  latter  case  the  uterus  closely  re- 
sembles the  normal  condition  ;  there  is  always  a  shallow  excavation  of 
the  fundus  between  the  projecting  horns ;  the  uterine  cavity  is  either 
simple  or  divided  by  a  septum  of  varying  length. 

The  part  that  unites  the  two  uterine  halves  always  represents  the 
fundus  uteri ;  the  higher  it  is  placed,  the  more  this  character  becomes 
evident ;  and  when  it  attains  the  same  level  as  the  uterine  horns  and 
surmounts  them  with  its  arch,  the  form  of  the  two-horned  uterus  disap- 
pears. We  consequently  find,  firstly,  that  the  commissure  in  all  cases 
occupies  a  horizontal  position  in  the  angle  in  which  the  two  uterine 
halves  meet. 

Secondly.  That  the  commissure  is  always  developed  in  conformity  with 
the  fundamental  type,  viz.  that  it  is  a  portion  of  uterine  tissue  presenting 
an  arch  posteriorly,  or  rather  being  obtuse-angled  and  thicker  behind. 


THE    UTERUS.  209 

Thirdly.  That  when  a  septum  exists  it  always  proceeds  from  the  com- 
missure. 

Fourthly.  That,  however  low  the  commissure  be  placed,  it  exerts  an 
evident  influence  upon  the  mutual  position  of  the  two  uterine  halves  and 
the  internal  conformation  of  their  cervices.  This  consists,  in  the  first 
instance,  in  the  slight  convexity  of  the  posterior,  and  the  slight  concavity 
of  the  anterior,  surface  of  the  uterus  hicornis ;  and  in  the  peculiar  rela- 
tion of  the  two  uterine  halves  to  one  another,  which  is  marked  by  a 
slight  convergence  and  inclination  anteriorly,  thus  affording  the  charac- 
ter of  a  normal  uterus.  The  influence  too  that  is  exerted  upon  the  pal- 
mae  plicatse  in  the  uterine  halves  is  singular ;  the  anterior  one  is  placed 
internally  next  to  the  septum,  the  posterior  one  lies  more  externally, 
and  on  account  of  the  greater  thickness  of  the  fundus  uteri — correspond- 
ing to  the  normal  character — more  towards  the  posterior  surface.  The 
fact  of  the  fundus  being  wedged  in  between  the  cervices  in  its  original 
form,  causes  the  palma  plicata  posterior  to  diverge  still  more ;  it  induces 
a  slight  rotation  of  the  uterine  halves  anteriorly,  which  is  followed  by 
the  above-described  form  and  position  of  the  uterus  bicornis. 

The  septum,  which  descends  from  the  fundus  uteri,  may  reach  down 
to  the  os  tincse  and  divide  it,  or  it  does  not  reach  so  far,  and  then  the 
orifice  or  the  cervix  is  common  to  both  halves,  or,  lastly,  it  may  be 
nearly  or  totally  absent,  and  we  then  find  the  cavity  of  the  cervix  and 
the  uterus  more  or  less  uniform,  in  proportion  as  the  fundus  itself  is 
more  or  less  elevated.  If  the  latter  is  much  depressed  and  presents  no 
septum,  a  single  cervical  channel  conducts  into  two  uterine  halves  that 
diverge  considerably,  sometimes  so  far  as  to  assume  a  horizontal  posi- 
tion. 

In  rare  cases,  the  two  uterine  halves  do  not  coalesce,  owing  to  coex- 
isting malformations,  such  as  fissures  of  the  abdominal  and  pelvic  parie- 
tes,  of  internal  organs,  especially  the  bladder  and  the  intestine ;  the 
uterus  thus  remains  completely  divided,  and  the  two  halves  are  separated 
by  the  rectum,  the  colon,  the  small  intestine,  or  by  a  rudimentary  por- 
tion of  either,  by  the  mesentery,  or  the  bladder.  In  the  majority  of 
cases,  the  inferior  section  of  both,  or  at  least  of  one  uterine  half,  is  but 
very  imperfectly  developed,  and  this  applies  still  more  to  the  vagina 
and  to  the  pudenda. 

The  lowest  degree  of  uterine  fissure  is  represented  by  the  bilocular 
uterus.  Here  the  projection  of  the  uterine  horns  has  entirely  disap- 
peared ;  the  fundus  uteri  occupies  a  position  level  with  the  orifices  of  the 
Fallopian  tubes,  and  its  convexity  projects  above  them.  The  uterine 
cavity  is  divided  into  two  vertical  partitions  by  a  central  septum ;  the 
uterine  horns  present  a  normal  divergence  and  the  normal  length.  Yet 
even  here  the  division  of  the  uterine  cavity  is  perceptible  externally ; 
the  body  of  the  uterus  presenting  greater  breadth,  and  generally  a  shal- 
low fundus,  in  consequence  of  which  the  uterus  appears  lower,  and 
its  dimensions  do  not,  in  most  cases,  exceed  those  of  the  normal  uterus ; 
the  division  is  also  indicated  by  a  shallow  furrow  running  down  the 
posterior  surface  of  the  organ. 

The  division  of  the  uterine  cavity  by  a  vertical  septum  into  two  loculi 
extends  in  rare  cases  into  the  external  orifice,  but  more  generally  is 

VOL.  II.  14 


210  ABNORMITIES    OF 

united  to  the  cavity  of  the  uterus,  or  the  septum  does  not  even  suffice  to 
divide  the  uterine  cavity :  when  this  malformation  approaches  the  nor- 
mal character  of  the  organ,  we  merely  observe  a  ridge  on  the  fundus  and 
along  the  posterior  wall  of  the  uterus,  representing  a  rudimentary  sep- 
tum. If  the  septum  does  not  reach  the  external  orifice,  its  lower  free 
border  is  always  thinner,  pointed,  and  falciform.  It  probably  always 
descends  lower  at  the  posterior  than  at  the  anterior  surface  of  the  uterus, 
and  this  becomes  particularly  apparent  when  it  merely  exists  in  a 
rudimentary  state. 

In  the  case  of  the  uterus  bicornis  or  bilocularis,  the  vagina  is  either 
single,  or  may  in  either  be  divided  in  all  the  forms  and  degrees  described 
at  p.  202.  The  most  perfect  fissure  seen  is  that  in  which  the  septum 
of  a  uterus  bicornis  or  bilocularis  descends  .  to  the  external  orifice, 
divides  the  latter,  and  extends  to  the  vagina ;  the  septum  may  reach  as 
far  as  the  pudenda,  and  in  the  virginal  state  divide  the  hymen.  In  this 
case  there  is  a  separate  vagina  for  each  half  of  the  uterus. 

All  these  malformations  of  the  uterus  occur  associated  with  various 
irregularities  in  other  organs,  as  also  in  individuals  that  in  other  respects 
are  well  developed.  In  reference  to  conception,  pregnancy,  and  partu- 
rition, connected  with  the  uterus  bicornis,  bilocularis,  and  unicornis,  we 
have  to  make  the  following  remarks. 

Firstly.  Numerous  well-authenticated  observations  prove  that  the  ano- 
malous conditions  of  the  uterus  which  we  have  discussed,  i.  e.  the  uterus 
bicornis  and  bilocularis,  with  or  without  division  of  the  vagina,  and  even 
the  uterus  unicornis,  are  capable  of  being  impregnated.  In  the  first  we 
find  repeated  pregnancy  occurring  in  either  half,  but  there  is  a  prepon- 
derance in  favor  of  the  right  side.  There  are  even  cases  on  record  of  a 
twin  pregnancy  occurring  in  one,  or  of  concurrent  pregnancy  in  both 
halves ;  one  fostus  has  been  found  less  developed  and  smaller,  and  in 
solitary  cases  perhaps — though  this  is  to  be  received  with  certain  doubts — 
superfoetation  had  taken  place.  In  the  Viennese  Museum  we  have  even 
an  example  of  pregnancy  in  a  rudimentary  uterine  horn,  which  termi- 
nated fatally  in  the  third  month  by  rupture  and  sanguineous  effusion  into 
the  peritoneal  cavity.  The  case  was  formerly  taken  for  impregnation  of 
the  Fallopian  tube,  until  a  further  examination  convinced  me  to  the  con- 
trary. It  is  highly  instructive,  and  doubtless  the  only  case  of  the  kind 
on  record.  We  shall,  therefore,  devote  a  little  further  attention  to  it. 

The  true  uterus  is  a  uterus  unicornis  of  the  left  side  with  a  cervix,  in 
which  cicatrices  that  have  been  left  by  former  births  are  visible  ;  the  left 
Fallopian  tube  issues  from  its  apex,  which  is  turned  to  the  left  side.  A 
tolerably  thick,  roundish,  flattened,  and  hollow  cord,  consisting  of  uterine 
parenchyma,  is  inserted  into  the  convex  right  margin  of  this  uterus,  and 
communicates  by  a  millet-sized  opening  just  above  the  internal  os  uteri 
with  the  cavity  of  the  latter.  This  cord  is  above  two  inches  in  length, 
and  is  dilated  externally  into  a  sac  of  the  size  of  a  duck's  egg,  from  the 
termination  of  which  the  right  tube  with  its  ovary,  and  from  the  lower 
surface  a  round  ligament  proceed.  This  sac,  the  rudimental  right  half 
of  the  uterus,  contained  a  female  foetus  of  the  third  month  enclosed  in 
the  normal  membranes ;  it  presented  a  transverse  fissure,  in  the  vicinity 
of  the  insertion  of  the  umbilical  cord,  of  almost  two  inches  in  length. 
All  the  membranes  were  ruptured.  The  left  half  of  the  uterus  is  twice 


THE     UTERUS.  211 

as  large  as  it  would  be  in  an  unimpregnated  state,  its  walls  thick,  and 
its  innner  surface,  as  well  as  that  of  the  channel  of  its  parenchymatous 
process,  invested  by  a  deciduous  membrane,  and  the  cervix  blocked  up 
with  a  plug  of  coagulable  lymph. 

The  preparation  was  taken  from  a  maid-servant  twenty-four  years  of 
age,  who  had  died  suddenly  after  attacks  of  pain  and  spasm  in  the  abdo- 
men on  the  24th  of  March,  1824,  and  was  examined  by  order  of  the 
sanitary  board.  The  body  was  delicately  built  and  rather  emaciated ; 
four  pounds  of  blood,  which  had  been  effused  in  consequence  of  the  rup- 
ture of  the  pregnant  rudimentary  uterus  and  the  foetal  membranes,  were 
found  in  the  lower  part  of  the  abdomen. 

The  formation  of  which  we  are  speaking,  is  the  same  as  the  transition 
form  from  the  uterus  bipartitus  to  the  uterus  bicornis  described  at  p.  208, 
with  the  exception  that  in  this  case  the  parenchymatous  cord  that 
passes  from  the  rudimentary  to  the  developed  half  of  the  uterus  is  hollow, 
and  contains  a  channel  which  establishes  a  communication  between  the 
two,  whereas  in  the  other  case  the  cord  is  solid.  By  means  of  this 
channel  impregnation  of  the  rudimentary  uterus  was  rendered  possible ; 
this  pregnancy  forms  a  species  of  transition  from  uterine  to  extra-uterine 
pregnancy,  and  particularly  to  pregnancy  in  the  Fallopian  tube. 

Secondly.  In  reference  to  the  course  of  pregnancy  and  of  parturition 
in  uterine  formations  that  are  capable  of  being  impregnated,  Meckel 
concludes,  from  a  review  of  the  cases  that  had  been  published  in  his  time, 
that  of  the  comparatively  small  number  of  cases  of  fissured  uterus  the 
majority  died  during  or  after  birth ;  this  ratio  is  increased  by  the  con- 
sideration that  in  the  great  majority  of  these  cases  the  malformations 
occurred  in  monstrosities,  children,  and  virgins.  Since  Meckel,  Carus 
has  directed  particular  attention  to  the  unfortunate  issue  of  these  cases. 
Numerous  cases  may  now  be  opposed  to  the  ancient  and  modern  ob- 
servations of  the  above  description,  but  it  appears  that  the  unfavorable 
ratio  pointed  out  by  Meckel  still  holds  good  with  regard  to  the  uterus 
bicornis  and  bilocularis. 

Various  circumstances  conspire  to  induce  great  distress  or  rupture  of 
the  womb,  even  during  the  early  periods  of  pregnancy  (Canestrini, 
Dionis),  to  give  rise  to  abortion,  flooding,  difficult  and  slow  parturition, 
with  consequent  exhaustion  and  predisposition  in  the  uterus  to  puerperal 
disease.  They  become  apparent  on  examining  the  fissured  organ,  and 
we  find  them  to  be  the  following. 

a.  The  absence  of  the  necessary  dimensions  in  the  uterine  half  that 
undertakes  the  functions  of  the  entire  organ  during  pregnancy,  and  the 
development  of  which  is  only  provided  for  by  one  set  of  vessels.     This 
applies  with  additional  force  to  a  rudimentary  uterine  half,  as  in  the  case 
just  detailed ;  in  reference  to  its  termination  in  rupture  also,  it  is  allied  to 
extra-uterine  pregnancy,  and  especially  to  pregnancy  in  the  Fallopian 
tubes. 

b.  The  obstacle  opposed  to  the  uniform  development  of  the  impregnated 
uterine  half  by  the  unimpregnated  half.     It  appears  that  the  latter,  after 
the  formation  of  a  more  or  less  complete  decidua,  keeps  pace  in  its  de- 
velopment with  the  impregnated  half  up  to  a  certain  point  only,  and  then 
remaining  stationary,  forms  an  impediment  to  the  uniform  growth  of  that 
half.     This  observation  is  particularly  applicable  to  the  bilocular  womb, 


212  ABNORMITIES    OF 

with  a  complete  septum,  as  the  latter  being  common  to  both  cavities,  re- 
mains undeveloped  on  the  side  of  the  unimpregnated  portion;  it  applies 
less  to  the  true  uterus  bicornis,  the  two  sides  of  which  are  independent 
of  one  another. 

<?.  The  nearer  the  uterine  malformation  approaches  the  uterus  bicor- 
nis, the  more  the  two  halves  of  the  organ  diverge  from  the  axis  of  the 
body  and  the  pelvis.  In  the  bilocular  uterus,  the  uterine  halves  are  tole- 
rably parallel  to  the  axis  of  the  body ;  in  the  uterus  bicornis  they  form 
an  acute,  or  even  almost  a  right  angle  with  the  latter.  The  impregnated 
half  of  the  uterus  certainly  shows  this  deviation ;  but  in  the  uterus  bicor- 
nis it  appears  to  diminish,  whereas  in  the  uterus  bilocularis  it  seems  to 
increase.  The  axis  of  the  impregnated  uterine  half  is  therefore  certain 
to  meet  with  the  vaginal  axis  in  an  obtuse  angle  ;  consequently,  during 
the  act  of  parturition,  the  direction  of  the  uterine  force  and  of  the  expul- 
sion of  the  foetus  will  cross  the  axis  of  the  pelvis,  and  fall  upon  the  pelvic 
parietes  that  lie  opposite  to  the  vertex  of  the  pregnant  half  of  the  womb. 
The  direction  of  the  impregnated  half  and  of  its  force,  will  also  be  influ- 
enced by  the  unimpregnated  half,  which  during  the  act  of  parturition  rests 
upon  the  pelvis,  and  especially  on  the  linea  innoininata  of  the  correspond- 
ing side. 

d.  The  fundus  uteri  and  its  expulsive  power  is  of  particular  importance 
in  the  act  of  parturition.     The  uterus  bilocularis  has  only  one  half  of 
this  part  of  the  organ,  and  in  the  uterus  bicornis  "it  is  totally  deficient. 

e.  Carus  considers  the  impediment  to  the  discharge  of  the  superfluous 
amount  of  blood  from  the  uterus  to  be  the  cause  of  the  fatal  issue  which 
commonly  follows  birth  in  the  case  of  fissured  uterus.     In  the  normal 
uterus  the  return  of  the  blood  accumulated  in  the  pregnant  womb  is 
effected  by  means  of  two  sets  of  vessels  ;  whereas  in  the  fissured  uterus, 
each  half  of  which  is  supplied  by  separate  vessels,  one-half  of  the  venous 
channels  only  can  carry  off  the  blood.      Consequently,  although  the 
single  uterine  horn  becomes  almost  as  much  developed  as  the  undivided 
uterus,  an  unfavorable  relation  is  established,  from  one  set  of  vessels 
only  being  charged  with  the  entire  quantity  of  blood  that  has  to  be  re- 
turned.    Besides  the  above  arrests  of  development,  we  find,  not  so  much 
in  new-born  infants  as  in  the  later  periods  of  life,  an  imperfect  develop- 
ment of  the  uterus  occurring  in  reference  to  its  size,  its  tissue,  and  espe- 
cially to  its  vascular  system ;  the  organ  remains  small  and  retains  the 
foetal  or  infantine  character. 

Excess  of  development,  except  in  the  shape  of  precocity,  does  not 
occur ;  the  cases  on  record  of  plurality  of  the  uterus  are  to  be  viewed  as 
cases  of  fissure. 

§  2.  Anomalies  of  Size. — These  consist  in  irregular  enlargement  or 
diminution. 

The  former  either  occurs  as  precocious  development,  depending  upon 
a  congenital  vice  or  accompanying  early  puberty,  or  it  is  the  result  of 
morbid  increase  of  size,  depending  chiefly  upon  hypertrophy  or  dilatation. 

Hypertrophy  either  affects  the  entire  uterus  uniformly,  so  that  its  nor- 
mal form  and  the  relations  of  the  different  parts  in  point  of  size  and 
capacity  are  preserved,  or  it  affects  one  segment  alone,  and  this  partial 
hypertrophy  is  particularly  remarkable  in  the  cervix. 


THE    UTERUS.  213 

The  hypertrophy  varies  in  degree ;  it  not  unfrequently  reaches  such  an 
extent,  that  the  uterus  attains  the  size  of  a  goose's  egg,  or  of  an  ordinary 
fist,  and  that  its  parietes  present  a  thickness  of  from  six  to  nine  lines. 

In  hypertrophy  of  the  cervix,  the  coexistent  malformation  is  remarkable. 
The  two  labia  of  the  os  tincse  often  enlarge  uniformly,  so  as  to  form  an 
annular  tumor ;  they  more  frequently  represent  two  cylindrical  swellings, 
separated  by  lateral  fissures  or  oblong  tumors  that  are  turned  up  outside ; 
still  more  frequently  we  find  the  anterior  lip  to  be  the  seat  of  hypertrophy, 
and  it  is  often  elongated  so  as  to  form  a  simple,  cylindrical,  or  conical 
teat-like  body,  or  if  the  cicatrices  resulting  from  previous  lacerations  pre- 
vent the  uniform  enlargement,  it  assumes  the  appearance  of  an  indented 
or  lobulated  appendix,  and  various  other  strange  shapes. 

Hypertrophy  is  caused  by  previous  and  repeated  pregnancy,  by  idio- 
pathic  or  consensual  irritation  of  the  uterus,  the  latter  involving  the  fre- 
quent coincidence  of  hypertrophy  of  the  uterus  with  diseases  of  the  mam- 
mary glands,  by  prolapsus,  and  by  tedious  vaginal,  and  especially  uterine 
catarrh.  Morbid  growths,  and  above  all,  fibrous  tumors  developed  in 
the  vicinity  of  the  uterine  mucous  membrane,  and  projecting  into  the 
cavity  of  the  uterus,  are  another  common  cause  of  hypertrophy;  on 
account  of  the  numerous  peculiarities  presented  in  these  cases,  we  have 
hitherto  excluded  them  from  our  investigation,  and  shall  leave  them  to 
be  discussed  at  a  future  period. 

Among  the  cases  of  dilatation  of  the  uterine  cavity,  we  have  first  to 
notice  the  one  in  which  it  is  complicated  with  hypertrophy  caused  by 
fibrous  polypi,  and  which  resembles  pregnancy,  and  then  those  important 
cases  in  which  the  dilatation  is  the  result  of  an  accumulation  and  reten- 
tion of  the  mucous  secretion  in  blennorrhoea,  and  of  tubercular  pus  in 
tuberculosis  of  the  uterus.  According  to  the  seat  of  a  stricture  or  of 
atresia  at  the  internal,  or  at  this  and  the  external  orifice  of  the  womb, 
we  find  the  uterus  converted  into  a  simple  globular,  or  into  an  hourglass- 
shaped  body ;  dilatation  of  the  proper  cavity  of  the  uterus  sometimes  attains 
such  a  degree  as  to  be  capable  of  containing  a  hen's  or  even  a  goose's 
egg.  We  shall  speak  of  this  under  the  head  of  acquired  anomalies  of 
the  shape,  as  well  as  under  that  of  textural  changes  of  the  uterus. 

Unusual  smallness  of  the  uterus  occurs  in  the  shape  of  arrested  deve- 
lopment, and  is  the  more  conspicuous  if  affecting  individuals  at  or  after 
the  age  of  puberty.  The  entire  uterus,  but  especially  its  neck  and  vagi- 
nal portion,  is  small,  dense  and  hard  in  structure,  and  anaemic,  its  mucous 
membrane  smooth  and  attenuated,  the  follicles  and  folds  undeveloped, 
and  the  remainder  of  the  sexual  apparatus,  and  particularly  the  ovaries, 
in  a  corresponding  state  of  imperfect  development.  The  affection  may 
also  consist  in  an  acquired  diminution,  reduction,  or  atrophy  of  the  uterus. 

Atrophy  generally  affects  the  entire  uterus  uniformly,  though  it  some- 
times predominates  in  the  cervix. 

Atrophy  of  the  entire  organ  is  presented  in  its  most  remarkable  form 
as  marasmus  or  senile  atrophy ;  sometimes  occurring  very  soon  after  the 
climacteric  change,  and  especially  in  consequence  of  tedious  catarrhs 
which  have  ceased  with  the  cessation  of  the  menstrual  discharge  ;  some- 
times occurring  even  before  this  period  from  debility  or  exhaustion  of 
the  uterus,  consequent  upon  a  rapid  succession  of  births,  or  upon  blennor- 


214  ABNORMITIES    OF 

rhoea.  This  condition  is  generally  combined  with  contraction  of  the 
uterine  cavity  (concentric  atrophy),  or  with  partial  contractions,  atresise 
of  the  cervix,  thinning  (atrophy)  of  the  uterine  mucous  membrane,  and 
accompanied  either  by  increase  of  density  and  coriaceous  toughness  of 
the  uterine  tissues,  or  by  another  change  of  peculiar  importance,  great 
friability  and  softness. 

A  thinning  of  the  uterine  walls  is  also  observed  to  occur  in  various 
degrees,  as  excentric  atrophy  in  the  above-named  dilatations  of  the  uterus. 

Atrophy  of  the  cervix  is  of  great  importance  on  account  of  its  occur- 
rence in  young  subjects  at  the  age  of  puberty,  and  from  its  probable  evil 
influence  upon  conception.  It  has  not  been  as  yet  clearly  demonstrated 
how  this  affection  is  caused.  The  cervix  becomes  smaller  in  consequence 
of  the  condensation  of  its  tissues,  and  at  the  same  time  the  arch  of  the 
vagina  is  considerably  diminished. 

Atrophy  of  the  entire  cervix  is  often  induced  by  the  tension  and  trac- 
tion resulting  from  the  consecutive  malpositions  of  the  uterus,  which  ac- 
company enlargements  of  the  ovaries  and  large  fibrous  tumors  of  the  ute- 
rus ;  in  the  latter  case  it  is  not  unfrequently  associated  with  hypertrophy 
of  the  body  of  the  uterus.  It  is  recognized  in  the  living  subject  by  the 
elongation  of  the  vagina,  and  the  concurrent  disappearance  of  the  cervix, 
and  the  conical  shape  of  the  vaginal  fornix.  In  rare  cases,  which  we 
shall  have  occasion  to  investigate  more  closely  at  a  future  period,  the 
affection  attains  such  a  degree  as  to  induce  solutions  of  continuity  in  the 
cervix. 

Diminution  of  the  uterine  cavity  presents  the  various  degrees  of  stric- 
ture, atresia,  and  obliteration. 

Strictures  and  atresise  occur  generally  at  one  or  both  orifices  of  the 
cervix,  but  rarely  at  other  points ;  from  here  they  occasionally  extend  so 
as  to  give  rise  to  a  partial  or  entire  obliteration  of  the  uterine  cavity. 
The  causes  of  their  origin,  both  in  reference  to  the  physiological  and 
pathological  conditions  of  the  organ,  have  not  as  yet  been  fully  explained. 
Our  own  observations  lead  us  to  adopt  the  view  that,  in  old  persons,  it  is 
caused  by  an  excessive  concentric  diminution  from  marasmus  (a  tendency 
in  the  retrograde  organ  to  complete  obliteration) ;  in  younger  individuals, 
by  chronic,  and  especially  by  gonorrhceal  catarrh  of  the  uterus. 

Contraction  of  the  internal  orifice  is  caused  by  concentric  atrophy, 
by  curvature  of  the  uterus,  or  sometimes  by  a  fine  duplicature  of  the 
mucous  membrane.  Atresia  of  the  passage  is  either  induced  by  delicate 
tendinous  deposits  of  epithelium,  or  by  agglutination  of  the  mucous  sur- 
faces ;  the  external  orifice  becomes  contracted  by  inflammatory  swelling, 
hypertrophy,  and  cancerous  degeneration  of  the  cervix ;  it  is  closed  up 
by  the  formation  of  a  whitish  layer  of  epithelium,  or  by  agglutination  of 
the  mucous  membrane  ;  or,  in  rare  instances,  by  parenchymatous  adhe- 
sion subsequent  upon  injury,  inflammation, •  and  ulcerative  loss  of  sub- 
stance. The  two  orifices  and  the  entire  cervix  may  also  be  blocked 
or  closed  up  by  hypertrophied  follicles,  mucous  polypi,  cancerous 
growths,  &c. 

3.  Anomalies  of  Form. — Besides  those  malformations  of  the  uterus 
which  we  have  alluded  to  as  resulting  from  arrest  of  development,  we 


THE     UTERUS.  215 

have  here  to  mention  congenital  obliquity  of  the  uterus.  Although  many 
doubt  its  existence,  occasional  opportunities  occur  of  observing  it  in  a 
greater  or  less  degree  of  development.  It  presents  several  varieties ; 
the  simplest  and  original  form  is  that  in  which  two  lateral  halves  of  the 
organ  are  so  changed  in  position  that  the  upper  margin  does  not  occupy 
the  horizontal  position,  and  that  consequently  one  horn  and  its  Fallopian 
tube  is  placed  higher  than  the  other,  and  the  cervix  presents  a  corre- 
sponding degree  of  obliquity.  The  upper  border  slants  to  either  side, 
and  its  axis  forms  an  angle  with  the  mesial  line ;  a  vertical  line  would 
divide  it  in  such  a  manner  that  the  greater  part  would  belong  to  the 
elevated  side.  The  inferior  half  of  the  uterus  is  generally  bent,  or 
forms  an  angle  at  the  internal  orifice,  the  higher  portion  being  at  the 
same  time  much  thicker  and  more  massive.  The  obliquity  may  confine 
itself  to  the  body  of  the  uterus,  and  the  latter  then  forms  an  angle 
with  the  cervix,  which  either  remains  perpendicular,  or,  in  rare  cases,  is 
even  deflected  in  the  opposite  direction.  A  slight  degree  of  this  anomaly 
is  presented  in  a  preponderating  development  of  either  horn.  In  many 
of  the  last-named  cases  the  uterus  assumes  the  appearance  of  a  retort. 

Obliquity  is  probably  of  importance  in  reference  to  conception,  preg- 
nancy, and  parturition.  It  must  be  distinguished  from  the  mere  slanting 
position  of  the  uterus. 

Among  the  acquired  malformations  we  first  notice  the  oblique  position 
induced  by  traction  exerted  upon  one  side  by  fibroid  tumors,  or  by  an 
enlarged  ovary  which  has  risen  into  the  abdomen.  Then  those  malfor- 
mations are  to  be  mentioned  which  the  uterus  presents  in  consequence  of 
traction  exerted  uniformly  on  both  sides,  of  fibrinous  tumors  developed 
within  its  parietes,  and  those  presented  by  the  vagina  in  hypertrophy, 
from  cicatrization  after  rupture  or  ulcerative  loss  of  tissue ;  lastly,  there 
are  the  malformations  accompanying  dilatation  of  the  uterine  cavity,  and 
the  development  of  a  uni-  or  bi-locular  capsule.  If  the  cavity  of  the 
uterus  alone  is  the  seat  of  an  accumulation  of  mucus,  owing  to  stric- 
ture or  obstruction  of  the  internal  orifice,  the  former  dilates  into  a  globe, 
which  appears  seated  upon  the  cervix  as  upon  a  stalk ;  if  a  similar  accu- 
mulation takes  place  in  the  channel  of  the  cervix  from  stricture  or 
atresia  of  the  external  orifice,  the  cervix  is  converted  into  an  ellipsoid 
capsule,  and  we  then  have  two  cavities,  one  above  the  other,  separated 
by  an  isthmus,  and  resembling  an  hourglass.  Mayer  has  termed  this 
malformation  of  the  uterus  the  uterus  bicameratus  vetularum. 

§  4.  Deviations  of  Position. — As  a  congenital  anomaly  of  this  variety, 
we  have  to  mention  the  oblique  position  of  the  womb,  brought  on  by 
shortness  of  one  of  the  broad  ligaments,  which  it  also  retains  in  the 
impregnated  state.  Among  the  acquired  deviations  of  position,  we  have 
first  to  mention  anteversion,  retroversion,  and  the  less  frequent  and 
less  important  lateral  deviations  of  the  uterus.  Retroversion  is  the  most 
frequent,  and  this  may  even  affect  the  pregnant  uterus. 

A  condition  to  which  hitherto  little  attention  has  been  paid,  consisting 
in  an  angular  deflection  of  the  fundus  from  the  cervix  uteri,  must  be  care- 
fully distinguished  from  the  two  former  irregularities.  This  deflection 
almost  always  takes  place  forwards  (Walshe's  anteflexion),  and  very  rarely 


216  ABNORMITIES    OF 

backwards  (retroflexion) ;  the  latter  never  considerable,  whereas  the 
former  not  unfrequently  attains  such  an  extent  that  an  angle  of  90°  and 
less  results.  The  fundus  uteri,  in  this  case,  occupies  a  horizontal  posi- 
tion, or  may  even  direct  its  posterior  surface  forwards ;  and  occupies  the 
cul-de-sac  placed  between  the  uterus  and  the  bladder.  This  deformity 
would  appear  to  be  an  excessive  increase  of  the  shallow  anterior  curva- 
ture developed  at  the  period  of  puberty,  and  a  separation  and  division  of 
the  uterine  cavity  from  the  channel  of  the  cervix,  consequent  upon  the 
preponderating  development  of  the  body  of  the  uterus.  It  is  of  impor- 
tance, as  it  induces  similar  symptoms  as  anteversion  and  retroversion, 
and  also  as  it  probably  interferes  with  conception  in  the  same  manner  as 
the  congenital  obliquities  that  are  complicated  with  similar  lateral  de- 
flections, viz.  from  contraction  of  the  internal  orifice. 

We  have  here  also  to  mention  prolapsus  of  the  womb,  which,  as  Fro- 
riep  has  satisfactorily  demonstrated,  may  occur  spontaneously  in  conse- 
quence of  traction  exerted  upon  the  womb  by  the  vagina,  in  the  shape 
of  hernia  vaginalis  posterior.  The  uterus  appears  extended  ;  in  conse- 
quence of  the  dilatation  of  the  venous  plexuses,  and  the  impediment  offered 
to  the  circulation  by  pressure,  it  becomes  the  seat  of  hypersemia ;  there 
is  increase  of  size  and  substance  (hypertrophy) ;  and  the  cervix,  at  the 
same  time,  from  being  exposed  to  atmospheric  and  other  influences,  is 
attacked  by  active  congestion,  increased  secretion,  exuberance  of  epithe- 
lium, inflammation,  &c.  Spontaneous  prolapsus  occurs  in  the  unimpreg- 
nated  uterus,  and  presents  various  degrees ;  so-called  accidental  prolap- 
sus is  developed  rapidly,  it  may  be  brought  on  immediately  or  soon  after 
parturition  by  direct  exciting  causes,  and  be  complicated  with  partial,  or 
in  rare  cases  with  complete,  eversion  of  the  uterus. 

Lastly,  we  find  the  position  of  the  uterus  variously  affected  by  en- 
largement or  dilatation  of  neighboring  organs,  by  pelvic  tumors,  mal- 
formations of  the  pelvis,  &c. 

§  5.  Deviations  of  Consistency. — We  shall  subsequently  advert  to  nu- 
merous deviations  in  the  consistency  of  the  uterine  parenchyma,  and 
especially  to  a  diminution  of  consistency,  resulting  from  various  morbid 
processes ;  but  an  increase  or  diminution  in  the  consistency  occurs  even 
without  apparent  disease  of  the  tissue. 

Diminished  consistency  is  not  only  presented  as  a  relaxation  of  the 
uterus  accompanied  by  marasmus,  consequent  upon  the  exhaustion  in- 
duced by  parturition,  or  arising  from  paralysis  of  the  uterine  fibre  in 
puerperal  diseases,  but  it  also  occurs  in  a  distinct  form  as  pulpiness 
(marciditas),  slight  friability  or  fragility.  It  very  frequently  affects  the 
decrepit  uterus,  involves  chiefly  the  fundus,  and  appears  generally  to 
result  from  exhausting  uterine  discharges.  The  tissue  of  the  affected 
uterus  is  of  a  pale  or  yellowish  red,  or  sometimes  ashy  color,  it  is  torn 
by  the  slightest  effort,  its  vessels  are  thickened,  rigid,  and  sometimes 
ossified.  This  condition  predisposes  more  particularly  to  apoplexy  of 
the  uterus  in  the  advanced  periods  of  life,  and  to  the  consequent  conver- 
sion of  the  uterus  into  a  sanguinolent,  dark-red,  and  subsequently,  rusty, 
lee-colored  pulp. 

This  condition  is  of  much  greater  importance  when  following  parturi- 


THE     UTERUS.  217 

tion  and  puerperal  morbid  processes  that  have  been  complicated  with 
phlebitis  ;  we  shall  have  occasion  to  speak  more  fully  of  this  tabes  uteri 
post  puerperium  in  the  sequel. 

The  uterus  presents  increased^  consistency  as  a  consequence  of  lasting 
hypersemia,  of  hypertrophy  or  even  of  atrophy ;  the  entire  organ,  or 
certain  portions  only,  as  e.  g.  the  cervix  being  affected.  There  are  vari- 
ous degrees,  from  coriaceous  condensation  and  toughness  to  fibroid  or 
cartilaginous  induration. 

§  6.  Solutions  of  Continuity. — Under  this  head  we  include  the  solitary 
cases  observed  by  old  writers,  of  rupture  of  the  pregnant  womb  about 
the  middle  of  pregnancy,  caused  by  a  deficiency  in  the  substance  of  the 
uterus  bicornis ;  the  more  frequent  rupture  of  the  uterus  at  its  superior 
portion,  in  consequence  of  excessive  labor-pains,  caused  by  insuperable 
obstacles  to  birth  on  the  part  of  the  mother  or  the  child,  and  accom- 
panied by  hemorrhage  and  escape  of  the  contents  into  the  cavity  of  the 
abdomen ;  and  the  still  more  common  rupture  of  the  uterus  at  its  lower 
segment  during  parturition,  in  consequence  of  various  difficulties. 

The  latter  generally  extends  from  the  cervix  to  the  vagina ;  it  may 
also  affect  the  parietes  of  neighboring  hollow  viscera,  especially  of  the 
bladder ;  the  blood  may  be  effused  into  the  pelvic  adipose  and  cellular 
tissue,  in  the  vicinity  of  the  bladder  and  the  rectum,  and  between  the 
broad  ligaments ;  it  may  pass  downwards  into  the  labia,  or  upwards  under 
the  peritoneum  into  the  iliac  and  lumbar  region ;  or  the  effusion  may 
be  accompanied  by  rupture  of  the  peritoneum  or  the  bladder,  and  take 
place  into  their  cavities.  These  ruptures  affect  the  entire  thickness  of 
the  uterine  or  vaginal  parietes,  or  are  limited  to  an  internal  layer,  or 
they  are  lacerations  of  the  vaginal  portion  of  the  uterus.  They  gene- 
rally have  a  vertical  direction,  transverse  lacerations  being  very  rare. 

In  cases  of  difficult  labor  the  uterus  may  be  subjected  to  contusions  of 
more  or  less  intensity,  which  sometimes  involve  the  entire  thickness  of 
the  organ.  The  parts  adjoining  the  promontory,  or  the  symphysis  pubis 
and  the  horizontal  rami  of  the  pubes  are  most  liable  to  suffer.  The  con- 
tusions may  affect  a  circular  spot  and  have  a  various  extent,  or  they  may 
be  chiefly  in  a  transverse  direction. 

In  rare  cases  the  uterus  suffers  a  severe  contusion  immediately  above 
the  vaginal  segment,  and  throughout  its  circumference,  amounting  even 
to  laceration ;  thus  the  vaginal  segment  of  the  uterus  may  at  once,  or  by 
a  subsequent  process  of  suppuration,  become  detached,  and  in  the  case 
of  eversion  of  the  uterus  after  parturition,  the  separation  of  the  entire 
uterus  from  the  vagina  has  been  observed  (Cook). 

Finally,  we  have  to  allude  to  ulcerative  affections  of  the  uterus  caused 
by  or  resulting  from  malignant  puerperal  disease,  and  in  various  other 
ways. 

§  7.  Diseases  of  Tissue. 

1.  Hypercemia — Apoplexy  of  the  Uterus — Anaemia. — Hypergemia  of 
the  uterus,  and  especially  of  its  mucous  membrane,  with  effusion  of  blood 
in  various  states  of  coagulation  and  discoloration,  is  often  observed  in  the 
dead  subject  as  menstrual  congestion  and  hemorrhage.  It  also  occurs 


218  ABXORMITIES    OF 

in  combination  with  tumefaction  (congestive  intumescence)  of  the  uterus 
and  its  appendages,  with  relaxation  of  its  parenchyma  and  the  mucous 
membrane,  dark  color,  copious  sanguineous  contents,  and  hemorrhage 
into  the  uterine  cavity,  representing  active  or  passive  congestion  or  me- 
chanical stasis,  consequent  upon  excessive  or  anomalous  menstrual  dis- 
charge, or  other  injurious  influences. 

Advanced  degrees  of  hyperaemia  give  rise  to  uterine  apoplexy,  i.  e.  to 
effusion  of  blood  into  the  uterine  parenchyma,  with  or  without  concur- 
rent hemorrhage  into  the  cavity  of  the  organ.  It  is  observed  in  two  dis- 
tinct forms. 

One  occurs  at  the  period  of  decrepitude,  and  is  chiefly  caused  by  the 
marcidity  of  the  uterine  tissue  above  alluded  to,  and  by  the  rigidity  of 
its  vessels ;  its  main  seat  is  the  fundus  uteri,  to  which  it  may  be  entirely 
limited,  or  at  which,  if  more  extensively  diffused,  it  has  taken  its  origin, 
and  is  most  prominently  developed.  The  fragile  and  softened  uterine 
tissue  presents  a  dark  red  or  black  discoloration,  extending  to  a  greater 
or  less  distance  from  within  outwards  ;  the  accumulation  of  blood  may  be 
so  considerable  as  to  destroy  all  traces  of  structure ;  it  oozes  from  the 
cut  or  broken  surfaces,  in  greater  or  smaller  quantities,  according  as  it 
is  more  or  less  coagulated.  The  mucous  membrane  presents  a  similar 
condition,  and  the  uterine  cavity  very  often  contains  more  or  less  slightly 
coagulated  or  fluid  blood.  The  posterior  wall  of  the  uterus  is  but  rarely 
affected,  and  if  so,  but  to  a  slight  extent. 

This  form  of  apoplexy  undoubtedly  constitutes  many  of  the  metror- 
rhagic  cases  that  occur  in  advanced  age  ;  the  lower  degrees  may  be  cured, 
the  tissues  subsequently  presenting  a  loose,  retiform,  contused,  and  por- 
ous appearance,  of  a  rusty  or  yellowish  color. 

The  second  form  results  from  tedious  and  slow  labors ;  it  occupies  the 
lower  segment  and  the  cervix  of  the  uterus.  The  affected  portion  ap- 
pears dark  rek,  and  full  of  blood  ;  the  part  'is  dilated,  relaxed,  pendulous 
and  paralyzed,  and  there  may  be  contusion  and  laceration  also. 

Anaemia  accompanies  an  arrest  of  development,  marasmus,  induration 
of  the  uterus,  and  general  anaemia. 

2.  Inflammation. — Although  we  shall,  as  much  as  possible,  distinguish 
between  the  mucous  membrane  and  the  uterus  itself  in  examining  this 
subject,  we  must  confess  that,  as  may  be  expected  from  the  close  ana- 
tomical connection  of  the  two,  the  diseases  which  we  shall  have  to  consider, 
very  readily  pass  from  the  one  to  the  other.  Yet  we  must  also  affirm 
that  generally  the  lining  membrane  of  the  uterus  is  affected  primarily, 
and  that  this  is  scarcely  ever  the  case  with  the  uterine  tissue,  as  far  as 
can  be  demonstrated  by  the  pathological  anatomist,  with  the  exception 
of  the  reaction  following  traumatic  influences,  especially  of  the  vaginal 
portion.  We  shall  not  at  this  place  devote  any  attention  to  peritoneal 
inflammation,  but  discuss  the  inflammatory  affections  of  the  unimpreg- 
nated  uterus,  and  the  participation  of  the  uterine  parenchyma  in  them. 
The  uterine  inflammations  occurring  after  childbirth,  with  their  sequelae, 
we  shall  consider  in  a  separate  appendix  on  puerperal  diseases  of  the 
uterus. 

a.  CatarrJial  inflammation  (endometritis  catarrhalis). — This  is  an 
acute  affection  ;  it  occurs  in  combination  with  inflammation  of  the  adja- 

\ 


THE    UTERUS.  219 

cent  uterine  tissues,  extending  to  a  greater  or  less  depth  and  of  various 
intensity,  and  even  complicated  with  peritonitis  ;  it  is  frequently  met 
with  in  the  sick-room,  but  rarely  in  the  dead-house :  it  is  here  only  oc- 
casionally observed  in  a  protracted  blennorrhoic  stage. 

The  uterine  mucous  membrane  is  much  more  commonly  discovered  in 
a  state  of  chronic  catarrh  and  inveterate  blennorrhrea,  which  is  either 
the  residue  of  acute  catarrh,  or  the  result  of  a  similar  affection  of  the 
vagina  ;  it  may  occur  as  a  sequela  of  parturition,  or  as  a  complication  of 
those  morbid  growths  that  bear  a  near  relation  to  the  uterine  mucous 
membrane.  The  mucous  membrane  offers  a  pallid  appearance,  or  there 
is  evidence  of  previous  stasis  and  inflammation,  and  it  then  presents,  with 
the  adjoining  uterine  tissue,  a  brownish-red  or  slaty  color ;  the  membrane 
is  tumefied,  relaxed,  plicated,  and  secretes  a  grayish-white  viscid  mucus, 
which  during  temporary  exacerbations,  or  an  enduring  state  of  more  in- 
tense inflammation,  appears  streaked  with  blood,  creamy,  yellow,  and 
puriform. 

Here,  too,  we  find  hypertrophy  of  the  mucous  membrane  resulting 
from  chronic  catarrh,  in  the  shape  of  mucous  or  cellular  polypi.  They 
consist  of  club-headed  elongations  of  the  mucous  membrane,  in  which  we 
find  a  group  of  closed  follicles,  or  a  lobulated  tissue  containing  a  gela- 
tinous mucus,  which  is  discharged  from  time  to  time  in  consequence  of  a 
dehiscence  of  the  follicles.  These  excrescences  occur  chiefly  at  the 
fundus  uteri,  in  the  neighborhood  of  the  insertions  of  the  Fallopian  tubes 
and  in  the  channel  of  the  cervix — a  point  at  which,  in  the  normal  con- 
dition, large  follicles  (ovuli  Nabothi)  are  found,  which  occasionally  un- 
dergo considerable  enlargement. 

We  find  that  the  uterine  parenchyma  becomes  more  or  less  hypertro- 
phied  during  catarrh,  in  the  same  manner  as  other  muscular  layers  which 
are  subjacent  to  mucous  membranes. 

Inveterate  uterine  catarrhs  not  unfrequently  give  rise  to  the  above- 
mentioned  strictures  and  atresiae ;  and  if  the  blennorrhoea  persists,  the 
dilatations  of  the  uterine  and  cervical  cavities  previously  discussed, 
result.  During  the  progress  of  dilatation  occurring  under  these  circum- 
stances, the  same  changes  tha\  we^have  already  repeatedly  met  with  under 
similar  circumstances,  in  dropsy  of  mucous  cavities  and  canals,  are  some- 
times found  to  occur  in  the  uterus.  As  a  dilatation  from  the  accumu- 
lated secretion  increases,  the  uterine  mucous  membrane  is  converted  into 
a  thin  serous  membrane,  which  secretes  a  colorless,  serous,  albuminous 
fluid,  resembling  synovia.  The  uterus  appears  in  the  shape  of  a  round, 
slightly-thickened,  hydropic  capsule,  of  the  size  of  a  hen's  or  duck's  egg 
or  a  fist.  This  condition  is  the  only  one  that  really  deserves  the  name  of 
hydrometra,  of  which  several  remarkable  instances  are  related,  especially 
by  older  writers.  The  contained  fluid  may  always,  or  for  a  long  time, 
remain  such  as  above  described ;  but  it  generally  undergoes  some  altera- 
tions from  the  admixture  of  various  products  of  slight  inflammatory 
attacks,  and  especially  of  hemorrhagic  exudations  of  the  uterine  lining, 
which  give  it  a  chocolate-colored,  rusty,  or  black  tinge. 

Occasionally  temporary  discharges  of  these  fluids  occur  by  the  vagina 
during  life,  after  which  fresh  accumulations  take  place.  They  are  to  be 
distinguished  from  similar  discharges  from  the  hydropic  Fallopian  tube. 

Uterine  catarrh  generally  suffices  to  produce  sterility ;  but  it  often  ex- 


220  ABNORMITIES    OF 

tends  to  the  Fallopian  tubes,  and  there  also  gives  rise  to  changes  that  are 
of  extreme  importance  in  this  respect. 

b.  Exudative  processes  (endometritis  exudativd). — Croupy  or  plastic 
fibrinous  exudation,  whether  or  not  accompanied  by  a  similar  process  in 
the  vaginal  or  Fallopian  mucous  membrane,  very  rarely  occurs  on  the 
inner  surface  of  the  uterus,  except  after  confinement.  It  is,  at  all  times, 
rather  a  secondary  than  a  primary  process.  Exudative  affections  of  the 
uterus  and  their  varieties,  occurring  after  parturition  in  the  shape  of  puer- 
peral diseases,  are  all  the  more  frequent  and  the  more  numerous. 

3.  Ulcerative  processes. — In  treating  of  catarrh  of  the  vagina,  we  have 
alluded  to  excoriation,  superficial  and  follicular  ulceration  of  the  vaginal 
portion  of  the  uterus.     The  specific  character  of  the  catarrh  and  the 
follicular  ulceration,  as  well  as  neglect  of  proper  attention  and  treatment, 
cause  the  resulting  ulcers  to  present  a  more  or  less  remarkable  appear- 
ance in  reference  to  the  shape  of  their  edges,  the  reaction  set  up,  the 
product  and  the  change  of  texture,  as  well  as  in  regard  to  the  consequent 
fusion  of  the  diseased  tissue,  and  to  the  concurrent  tendency  of  disorgani- 
zation beyond  the  ulcer.     It  is  stated  that,  in  reference  to  the  first  of 
these  considerations,  we  may  distinguish  the  simple  (catarrhal),  the  her- 
petic,  scabious,  and  scrofulous  ulcer  of  the  cervix ;  as  regards  the  local 
process,  there  may  be  a  fungous,  lardaceous,  or  callous  ulcer,  &c.     We 
also  find  primary  and  secondary  syphilitic  ulcers,  cancerous  ulcers  that 
have  resulted  from  the  fusion  of  cancerous  morbid  growths,  the  so-called 
phagedenic  ulcer  of  the  os  tincae  (Clarke's  corroding  ulcer).     The  latter 
may  be  compared  to  the  phagedenic  (cancerous)  sore  of  the  skin ;  without 
having  a  morbid  growth  for  its  base,  it  gradually  destroys  the  cervix,  and 
even  the  greater  part  of  the  uterus,  and  may  extend  to  the  rectum  and 
the  bladder.     It  is  an  irregular,  sinuous,  jagged  ulcer,  the  tissues  at  the 
margin  and  the  base  of  which  are  thickened  or  hypertrophied,  in  conse- 
quence of  a  sluggish  inflammatory  process  ;  the  base  presents  a  greenish 
and  brownish-green  discoloration,  with  a  slight  glutinous  and  purulent, 
or  a  more  copious  watery,  secretion :  there  are  no  granulations,  but  we 
find  a  gelatinous  exudation,  and  according  Jo  the  state  of  the  immediate 
reaction,  the  tissues  are  converted  into  the  above-mentioned  products  of 
the  ulcerating  surface. 

Lastly,  we  find  the  uterus  liable  at  different  parts,  and  in  a  varying 
extent,  to  acute  or  chronic  ulcerative  disorganization,  as  a  consequence 
of  puerperal  affections;  this  subject  will  be  examined  in  the  appendix. 

4.  Morbid  growths,     a.   Cysts. — Cysts  are  very  rarely  formed  in  the 
uterus  ;  we  have  not  met  with  a  single  example  in  Vienna,  and  I  myself 
have  only  inspected  one  case  of  uterine  acephalocysts.     It  is  necessary 
to  distinguish  the  very  much  hypertrophied  follicles  that  may  occur  in 
the  uterine  cervix,  from  newly-formed  cysts. 

b.  Fibroid  tumors. — Anomalous  fibrous  tissue  is  the  most  frequent  of 
all  new  formations  occurring  in  the  uterus,  in  the  shape  of  fibroid  or 
fibrous  tumors  (tumor  fibrosus,  desmoides,  formerly  called  sarcoma ;  when 
ossified,  osteosteatoma  of  the  uterus ;  scirrhus ;  W.  Hunter's  carneous 
tubercles,  &c.)  These  fibroid  growths  of  the  uterus  not  only  present  all 
the  essential  characters  peculiar  to  them  elsewhere  in  a  remarkable 
degree,  but  they  also  offer  numerous  important  and  accidental  modifica- 


THE     UTERUS.  221 

tions,  some  of  which  exert  a  considerable  influence  upon  the  uterus ;  it 
therefore  becomes  necessary  to  devote  a  more  extended  consideration  to 
them,  in  addition  to  the  general  outline  which  we  have  already  given. 
The  uterus,  as  well  as  the  adjoining  tissues,  are  particularly  liable  to  be 
the  seat  of  fibroid  growths.  They  not  only  present  all  the  varieties  and 
degrees  as  regards  size  and  volume,  shape,  number,  and  metamorphosis, 
in  so  characteristic  a  form,  that  we  have  thought  it  right  to  take  them  as 
the  specimen  and  groundwork  of  general  disquisitions  on  the  subject,  but 
they  also  offer  the  most  various  modifications  in  reference  to  their  seat, 
and  consequent  reflex  influence  upon  the  womb. 

We  also  find  that  the  changes  in  position  of  the  uterus,  the  deviations 
of  its  shape,  and  of  the  direction  and  form  of  its  cavity,  of  its  size  in 
reference  to  the  coexistent  hypertrophy  and  atrophy  of  the  organ,  and 
the  relations  of  the  uterine  mucous  membrane,  &c.,  are  very  remarkable. 

The  three  varieties  distinguishable  in  the  fibroid  tumor,  according  to 
its  internal  structure,  are  all  found  in  the  uterus.  The  variety  in  which 
a  concentric  disposition  of  the  fibres  is  displayed,  is  here  also  distinguished 
by  its  density,  hardness,  poverty  of  vessels,  smallness,  and  spherical 
shape. 

The  second  variety,  in  which  the  fibres  appear  irregularly  disposed, 
and  issue  from  numerous  centres  or  nuclei,  present  a  rounded  form,  and 
an  uneven,  nodulated  surface,  which  indicates  the  aggregation  of  the 
fibrous  centres  in  reference  to  density  and  consistency,  vascularity  and 
volume,  they  offer  the  extensive  modifications  already  spoken  of;  they 
may,  on  the  one  hand,  be  very  dense  and  hard,  and  unvascular ;  on  the 
other,  in  consequence  of  an  accumulation  of  cellular  tissue  in  the  inter- 
stices of  the  fibrous  layers,  they  may  be  more  or  less  vascular  and  suc- 
culent, or  soft  and  elastic,  soft  and  doughy,  flabby,  &c.,  sometimes  re- 
sembling a  soft  mammary  gland,  sometimes  a  coarse-grained  salivary 
gland.  Those  fibroid  tumors,  the  interstices  of  which  are  dilated  into 
cells  or  cavities,  containing  a  serous  fluid  from  excessive  exhalation  of  the 
intervening  cellular  tissue,  are  of  extreme  importance.  They  present 
fluctuation,  and  may,  on  account  of  the  deceptive  appearances  accompany- 
ing fibroid  tumors,  be  easily  mistaken  for  ovarian  dropsy,  hydrometra, 
acephalocyst  of  the  uterus,  or  pregnancy. 

The  fibrous  polypus  of  the  uterus,  the  third  variety  of  fibroid  tumors, 
takes  it  origin  by  a  single  or  divided  trunk  in  the  interstitial  cellular 
tissue  of  the  uterine  parenchyma ;  the  former  expands  into  striated  fasci- 
culi, which  are  bound  together  by  softer  vascular  and  cellular  interstitial 
substance,  and  the  entire  mass  presents  a  distinctly  lobulated  structure, 
which  is  more  or  less  visible  externally.  The*  polypus  grows  into  the 
cavity  of  the  uterus,  with  which  it  is  in  the  closest  anatomical  connection, 
and  upon  the  functions  of  which  it  exerts  a  considerable  influence.  It 
enlarges  chiefly  in  one  direction,  and  has  a  cylindrical,  fusiform,  clubbed, 
pyriform  shape,  and  is  more  or  less  flattened ;  it  is  provided  with  nume- 
rous and  very  large  vessels,  is  apt  to  swell,  and  in  consequence  of  exces- 
sive congestion  and  rupture  of  the  vessels,  we  often  meet  with  extrava- 
sation within  its  tissues. 

The  anatomical  relation  of  fibroid  tumors  to  the  uterine  parenchyma 
is  very  intimate  in  the  third  variety,  less  so  in  the  second,  and  least  of  all 


222  ABNORMITIES    OP 

in  the  first,  in  which  the  tumors  adhere  to  the  uterine  parietes  by  a  thin 
layer  of  whitish  or  reddish,  more  or  less  vascular,  cellular  tissue,  so  that 
they  may  be  detached  without  difficulty. 

The  form  of  the  fibroid  tumors  of  the  first  and  second  variety,  we  have 
already  described  as  being  generally  round ;  in  the  second  variety  some 
alterations  may  occur,  though  the  globular  form  still  predominates.  The 
peculiarities  of  shape  of  the  fibrous  polypus,  or  third  variety  have  already 
been  stated.  The  greatest  variety  occurs  in  reference  to  size.  Fibroid 
tumors  are  found  from  the  size  of  a  hemp-seed  to  that  of  a  man's  head. 

The  fibroid  tumors  belonging  to  the  second  variety  attain  the  largest 
size,  especially  when  of  loose  texture,  and  rich  in  interstitial  cellular  tis- 
sue ;  the  fibrous  polypi  also  reach  a  considerable  magnitude,  but  the 
fibroid  tumors  of  the  first  variety  are  the  smallest.  They  are  all  gene- 
rally developed  slowly,  though  the  second  and  third  variety  are  occa- 
sionally developed  with  extraordinary  rapidity  ;  they  are  also  liable  to  a 
temporary  increase  of  size  or  tumefaction  proportionate  to  their  vascu- 
larity. 

As  to  their  number,  we  sometimes  only  find  a  single,  sometimes  seve- 
ral or  many  fibroid  tumors  in  the  same  uterus.  We  then  observe  tumors 
of  the  most  different  sizes  coexisting.  This  applies  chiefly  to  the  first 
two  varieties ;  the  fibrous  polypus  is  often  solitary,  but  it  also  occurs  in 
company  with  the  others. 

The  uterine  parietes  are  the  seat  of  the  fibroid  tumors,  but  not  only 
do  they  occur  much  more  frequently  in  the  body  than  in  the  cervix,  but 
in  the  former  they  chiefly  affect  the  upper  portion  or  fundus.  They  very 
rarely  occur  at  the  inner  orifice,  and  if  possible,  still  less  frequently  in 
the  vaginal  portion.  This  is  the  case  with  all  fibroid  tumors,  a  fact  that 
forms  an  interesting  contradistinction  to  the  relation  which  cancerous 
disease  bears  to  the  inferior  segment  of  the  uterus.  Fibrous  polypus, 
more  especially,  is  apt  to  commence  at  the  fundus,  and  at  the  orifices  of 
the  Fallopian  tubes.  The  fibroid  tumor  is  inserted  into,  and  takes  its 
origin  from,  the  middle  layers  of  the  uterine  substance,  or  it  appears  to 
be  more  connected  with  the  external  layer,  or  even  to  lie  under  the  peri- 
toneum, or  again,  it  lies  nearer  the  inner  surface,  or  immediately  under 
the  mucous  membrane.  The  first  two  varieties  are  developed  in  the  most 
various  layers,  though  generally  in  the  external  ones ;  the  third  forms 
upon  the  internal  layer  exclusively.  The  former  also  very  frequently 
present  other  curious  relations,  whether  they  have  been  developed  in  the 
vicinity  of  the  peritoneum,  or  of  the  mucous  membrane  of  the  uterus. 
In  the  first  instance  the  tumor,  as  it  enlarges,  gradually  becomes  detached 
from  the  uterus,  dragging  the  peritoneum  after  it,  and  thus  at  last  becomes 
pediculated  or  pendulous,  by  a  peritoneal  cord  of  various  length.  In  the 
second  instance  it  pushes  the  mucous  membrane  before  it,  as  it  enlarges, 
and  at  last  hangs  into  the  uterus  by  a  mucous  pedicle,  thus  resembling 
the  true  fibrous  polypus,  from  which  it  may  be  distinguished  by  its  rela- 
tion to  the  uterine  parenchyma,  and  by  its  internal  structure. 

We  must  here  advert  to  a  circumstance  that  is  not  of  very  rare  occur- 
rence, viz.  we  sometimes  find  a  fibroid  tumor  in  the  pelvic  cavity,  and 
generally  in  Douglas's  space,  without  any  further  connection  with  the 
uterus,  except  by  means  of  cellular  cords,  or  laminae  of  new  formation 


THE    UTERUS.  223 

(false  membranes),  which  pass  from  the  tumor  to  the  uterus  and  its  ap- 
pendages, to  the  pelvic  walls,  the  rectum,  £c.  The  question  presents 
itself,  which  is  the  original  point  of  development  of  such  fibroid  tumors. 
They  are  generally  tumors  which  have  originally  been  developed  under 
the  uterine  peritoneum,  and,  after  having  become  entangled  in  a  network 
of  pseudo-membranous  formations,  resulting  from  the  peritonitis  they  have 
excited,  are  gradually  detached  from  the  uterus.  Occasionally,  however, 
they  may  have  been  developed  within  the  false  membranes  themselves, 
which  is  the  more  probable,  if  we  consider  that  the  new  tissue  as  it  pro- 
ceeds from  the  uterine  peritoneum,  participates  in  the  character  of  the 
subserous  uterine  cellular  tissue.  Hence  it  is  extremely  likely  that  we 
really  see  very  small  fibroid  tumors  occasionally  developed  in  this  new 
tissue. 

To  these  fibroid  tumors,  the  loose  fibrous  concretions  which  are  some- 
times found  in  the  pelvic  cavity  are  allied ;  they  must  be  considered  as 
fibroid  tumors  of  the  uterus,  which  have  become  detached  in  consequence 
of  atrophy  of  the  peduncle. 

Metamorphoses  and  diseases  of  the  uterine  fibroid  tumors.  Spontane- 
ous cure. — We  have  already  spoken  of  ossification,  congestion,  inflam- 
mation, suppuration,  and  solution  of  fibroid  tumors  generally  ;  and  those 
remarks  apply  with  the  more  force  to  uterine  fibroid  tumors,  as  we  as- 
sumed the  latter  as  the  foundation  upon  which  we  based  our  observations. 
Ossification  occurs  very  frequently,  congestion  less  so,  and  inflammation 
and  its  terminations  rarely.  A  spontaneous  cure,  under  which  head  we 
must  also  class  ossification,  on  account  of  the  destruction  of  vitality  in 
the  tumor,  occurs  in  a  few  rare  cases,  by  a  detachment  of  the  fibroid 
tumor  as  it  projects  into  the  uterus,  or  is  suspended  in  it  by  a  mucous 
pedicle.  It  is  effected  in  the  following  manner :  the  mucous  membrane 
of  the  uterus  covering  the  apex  of  the  tumor  is  in  a  condition  of  perma- 
nent irritation  and  congestion  ;  this  is  at  last  converted  into  inflamma- 
tion, and  terminates  in  suppuration  and  gangrene.  The  tumor  is  thus 
partially  exposed  towards  the  uterine  cavity,  and  the  destructive  process 
gradually  involving  its  entire  cellular  investment,  it  becomes  detached, 
and  passes  through  the  opening  in  the  uterine  mucous  membrane  into 
the  uterine  cavity.  Ancient  and  modern  cases  are  on  record,  in  which 
fibroid  tumors  of  various  sizes  and  ossified  tumors  were  thus  discharged. 
The  powers  of  nature  rarely  suffice  if  the  tumors  are  of  considerable  size, 
as  the  extensive  suppuration  necessary  for  that  purpose  is  likely  to  prove 
fatal,  both  by  exhaustion  and  by  the  extension  of  inflammation  to  neigh- 
boring organs.  It  would  appear  that  the  fibrous  polypus  is  occasionally, 
though  very  rarely,  discharged  in  a  similar  manner,  in  consequence  of 
suppuration  occurring  at  its  roots  and  in  the  surrounding  tissues. 

The  changes  in  the  uterus,  consequent  upon  the  presence  of  one  or  of 
several  large  fibroid  tumors,  are  numerous  and  important,  by  reason  of 
the  diagnostic  characters  they  afford. 

In  the  first  instance,  the  volume  of  the  uterus  increases  in  proportion 
to  the  number  and  size  of  the  tumors  ;  the  fibrous  polypus  causes  an  en- 
largement of  the  uterine  cavity,  corresponding  to  the  size  of  the  polypus. 
The  increase  in  the  substance,  the  hypertrophy  of  the  uterus,  which  the 
fibroid  growths  generally  induce,  and,  on  the  other  hand,  the  atrophy  of 


224  ABNORMITIES    OF 

the  organ,  are  of  greater  interest.  The  hypertrophy  appears  as  a  de- 
velopment of  the  uterine  tissue,  resembling  that  occurring  in  pregnancy ; 
it  varies  in  degree.  In  reference  to  the  latter  subject,  the  question  pre- 
sents itself  by  what  means  the  different  degrees  of  hypertrophy  are  de- 
termined, and  on  account  of  the  occasional  passive  condition  and  the 
occasional  atrophy  of  the  uterus,  it  is  necessary  still  further  to  generalize, 
and  to  ask  how  it  happens  that  under  some  circumstances  the  uterus  be- 
comes hypertrophied,  in  others  remains  unchanged,  and  in  others  again 
becomes  atrophic  ?  In  answer,  we  offer  the  following  remarks  : 

«.  The  nearer  the  fibroid  growths  approach  to  the  uterine  mucous 
membrane,  and  project  into  the  cavity  of  the  uterus,  and  thus  maintain 
the  mucous  membrane  in  a  state  of  irritation  and  inflammation,  the  more 
palpable  is  the  hypertrophy  of  the  uterus.  It  is  most  fully  developed, 
so  as  to  resemble  pregnancy,  in  the  case  of  the  fibrous  polypus. 

/?.  Hypertrophy  of  the  uterus  appears  to  be  encouraged  by  a  vascular 
state  of  the  tumor,  by  the  latter  being  less  dense  and  capable  of  rapid 
growth. 

Y.  As  also  by  the  development  of  the  tumor,  during  or  shortly  after 
the  period  of  conceptivity. 

3.  The  size  of  the  tumor  exerts  no  direct  influence  upon  the  origin  of 
hypertrophy  or  atrophy. 

e.  Atrophy  undoubtedly  results  very  rarely  from  fibroid  tumors,  nor 
must  we  forget  that  they  are  not  unfrequently  developed  in  the  uterus 
during  the  period  of  decrepitude,  and  that  they  increase  very  slowly  on 
account  of  the  universal  state  of  marasmus.  In  this  case  the  atrophy 
of  the  uterus  is  entirely  independent  of  and  antecedent  to  the  fibroid 
tumors. 

The  atrophy  of  the  cervix  accompanying  large  fibroid  growths  is,  as 
we  shall  have  occasion  to  explain  more  fully,  the  result  of  mechanical 
traction. 

An  important  change  takes  place  in  the  position  of  the  uterus,  which 
may  be  discovered  by  external  examination.  Not  only  does  a  large 
fibroid  tumor  that  occupies  the  external  layer  of  the  uterine  tissue,  push 
the  organ  to  the  opposite  side  of  the  pelvis,  but  we  also  notice  a  remark- 
able ascent  of  the  organ.  The  more  numerous  and  the  larger  the  tumors 
are,  and  the  more  they  consequently  rise  out  of  the  pelvis,  as  it  interferes 
with  their  growth,  the  more  they  drag  the  uterus  after  them ;  its  vertical 
position  being  also  changed  in  proportion  as  the  fibroid  tumors  prepon- 
derate on  one  side  or  the  other.  This  traction  necessarily  causes  an 
elevation  and  elongation  of  the  cervix. 

The  external  surface  of  the  uterus  is,  as  may  be  easily  understood, 
variously  disfigured  by  the  projecting  tumors.  In  the  same  manner  the 
cavity  of  the  uterus,  in  addition  to  a  corresponding  elongation,  undergoes 
various  alterations  in  form  and  direction,  proportionate  to  the  number 
and  size  of  the  tumors  which  project  internally.  In  reference  to  the 
displacement,  we  sometimes  find  the  entire  cavity  forced  out  of  the 
mesial  line,  at  others  it  presents  more  or  less  angular  deflections.  The 
most  important  disfiguration  is  effected  by  the  upward  traction  exerted 
by  numerous  and  large  fibroids.  The  uterus,  and  particularly  the  cervix, 
is  elongated  to  a  degree  proportioned  to  the  degree  of  traction,  it  be- 


THE    UTERUS.  225 

comes  thinner,  and  the  attenuation  may,  in  rare  cases,  even  cause  a 
gradual  solution  of  continuity,  one  portion  remaining  attached  to  the 
vagina,  another  following  the  upward  direction  of  the  uterus,  and  the 
connection  being  maintained  by  a  mere  band  of  cellulo-fibrous  tissue. 
The  channel  of  the  cervix  at  the  same  time  contracts,  and  may  even  be- 
come entirely  obliterated.  The  vaginal  portion  gradually  disappears, 
the  vagina  itself  becomes  smooth  and  narrower  in  consequence  of  the 
elongation,  and  its  arch  is  converted  into  a  funnel,  the  apex  of  which  ter- 
minates in  the  os  uteri. 

If  one  or  more  fibroid  growths  occupy  a  lateral  portion  of  the  uterine 
parietes,  and  especially  if  they  be  seated  in  the  vicinity  of  the  Fallopian 
tubes,  the  external  form  of  the  uterus  may  be  rendered  oblique  ;  if  under 
these  circumstances  the  tumors  enlarge,  and  consequently  exert  lateral 
traction,  this  may  be  recognized  by  the  elevation  of  the  corresponding 
side  of  the  os  tincse,  and  the  increased  distension  of  the  vagina. 

Fibrous  polypus  gives  rise  to  a  dilatation  of  the  uterine  cavity,  and  of 
the  cervix,  corresponding  to  the  size  of  the  morbid  growth ;  if  the  en- 
largement proceeds  to  a  greater  extent,  the  external  orifice  becomes  di- 
lated, and  the  tumor  projects  through  it  into  the  vagina.  Large  and 
heavy  morbid  masses  of  this  description  frequently  cause  a  slight  descent 
of  that  portion  of  the  uterus  into  which  they  are  inserted,  by  the  trac- 
tion they  exert,  and  sometimes  even  induce  complete  inversion  of  the 
womb. 

The  mucous  membrane  of  the  uterus  is  the  more  liable  to  catarrh  and 
blennorrhoea,  the  nearer  the  fibroid  tumor  approaches  to  it ;  sometimes 
it  becomes  hypenemic,  and  blood  is  effused  upon  it.  This  is  particularly 
the  case  with  the  fibrous  polypus,  which  is  not  only  accompanied  by  the 
ordinary  hemorrhage  from  the  capillaries  of  the  mucous  membrane,  but 
also  from  larger  vessels  of  the  uterus,  or  sinuses  of  the  morbid  growth 
that  have  given  way  to  excessive  traction. 

Fibroid  tumors  of  the  uterus  scarcely  ever  occur  before  the  twentieth 
year  ;  a  fact  which  is  established  by  the  numerous  observations  made  by 
ourselves  and  other  anatomists.  They  are  even  unusual  up  to  the 
thirtieth,  and  present  themselves  most  frequently  shortly  after  the 
fortieth  year.  Without  entering  into  an  analysis  of  the  almost  innume- 
rable cases  that  we  have  ourselves  met  with,  we  may  mention  the  results 
of  Bayle's  calculations  as  to  the  frequency  of  their  occurrence  ;  he  states 
that  of  one  hundred  females  that  die  after  the  thirty-fifth  year  of  life, 
twenty  at  least  are  affected  with  fibroid  tumors. 

They  are  found  in  complication  with  the  most  various  morbid  growths 
of  the  uterus  and  its  appendages ;  but  especially  with  cancer  of  the 
cervix,  with  the  corroding  ulcer  of  the  os  tincse,  with  ovarian  dropsy,  &c., 
still  on  the  whole  the  complication  with  cancer  is  not  frequent. 

The  powers  of  conception  are  commonly  not  impaired  by  the  presence 
of  fibroid  tumors,  and  if  these  are  small,  and  do  not  occupy  an  unusual 
position,  they  have  not  necessarily  an  injurious  influence  upon  pregnancy 
and  parturition,  though  they  frequently  cause  abortion  and  hemorrhage 
after  birth.  Parturition  may  be  very  much  impeded  if  they  occupy  the 
cervix  uteri.  It  is  important  to  know  that  these  tumors  become  more 
vascular,  succulent,  and  softened  during  pregnancy,  and  assume  a  bluish- 

VOL.  II.  15 


226  ABNORMITIES     OF 

red  color,  so  that  their  original  appearance  is  entirely  changed.  As  the 
uterus  returns  to  its  original  shape,  the  morbid  growth  also  resumes  its 
ordinary  characters.  Pregnancy  is  even  said  to  give  rise  to  hemorrhage 
and  inflammation  in  the  tissue  of  the  fibroid  tumor. 

An  unusual  though  very  important  occurrence,  brought  on  by  the  ex- 
cessive expansion  and  traction  exerted  by  large  fibroid  tumors,  is  the  lace- 
ration of  the  vessels,  and  especially  of  the  veins.  We  have  once  observed 
the  rupture  of  a  vesical  vein  (with  that  of  the  mucous  membrane)  followed 
by  hemorrhage  into  the  bladder,  and  in  another  case  the  rupture  of  the 
subperitoneal  vein  of  a  fibroid  tumor,  with  hemorrhage  into  the  abdomi- 
nal cavity,  as  described  by  other  writers. 

Ligature  of  the  fibrous  polypus  is  sometimes  followed  by  uterine  phle- 
bitis. 

5.  Osteoid  growths. — We  have  not  met  with  osseous  formations  in  the 
uterus,  except  in  the  shape  of  ossification  of  the  fibroid  tumors. 

6.  Tubercle. — Tubercle  occurs  primarily  as  tubercle  of  the  uterine 
mucous  membrane ;  the  uterine  parenchyma  is  like  the  submucous  muscular 
layers,  only  attacked  secondarily  by  tubercle. 

It  generally  occurs  in  the  uterine  mucous  membrane  in  the  shape  of 
an  infiltrated  mass,  which  fuses  into  and  attacks  the  uterine  parenchyma 
to  a  greater  or  less  extent.  The  mucous  membrane  appears  converted 
into  a  fissured,  cheesy,  purulent  mass  of  tubercle.  The  cavity  of  the 
uterus  contains  tubercular  pus,  which  may  be  retained  in  consequence 
of  closure  of  the  orifice,  and  accumulate  so  as  to  cause  a  globular  dis- 
tension of  the  organ.  The  disease  is  very  rarely  observed  in  its  early 
stage,  in  the  shape  of  scattered  or  grouped  gray  miliary  tubercle  of  the 
mucous  membrane  and  the  adjoining  submucous  tissue. 

Uterine  tubercle  is  formed  during  childhood,  in  the  period  of  puberty, 
and  during  the  prime  and  even,  though  rarely,  during  the  decline  of 
life.  It  is  most  frequently  complicated  with  tubercle  of  the  Fallopian 
mucous  membrane,  and  with  the  latter  may  constitute  the  primary  tuber- 
cular affection.  It  is  also  found  complicated  with  abdominal  tubercle, 
and  especially  of  the  abdominal  lymphatic  glands,  and  of  the  perito- 
neum ;  and  may  serve  as  a  point  of  discharge  for  the  latter.  A  transla- 
tion of  the  tubercular  disease  to  the  urinary  passages  is  very  rarely 
observed. 

It  is  curious  that  the  tubercular  deposit  stops  short  at  the  cervix,  and 
very  rarely  passes  even  beyond  the  internal  orifice  of  the  womb ;  the 
vaginal  portion  is  never  affected  with  tubercular  disease.  This  is  ex- 
tremely remarkable  on  account  of  the  marked  contrast  offered  by  carci- 
noma, both  in  reference  to  its  primary  and  secondary  development. 

7.  Carcinoma. — Next  in  frequency  to  fibroid  growths  is  the  occurrence 
of  cancer.     It  always  attacks  the  cervix  in  the  first  instance,  and  espe- 
cially that  portion  which  projects  into  the  vagina ;  the  primary  occurrence 
of  carcinoma  at  the  fundus  uteri  is  so  extremely  rare,  that  the  above  obser- 
vation may  be  considered  as  an  absolute  rule.     It  is  contrasted  in  this 
respect  with  fibroid  and  tubercular  disease  of  the  uterus,  and  it  presents 
a  similar  contrast  in  reference  to  its  extension  and  ulcerative  destruction. 

According  to  our  observations,  fibrous  cancer  very  rarely  affects  the 
uterus  ;  the  most  common  form  is  the  medullary,  either  by  itself  or  com- 
plicated with  the  former. 


THE    UTERUS.  227 

Opportunities  very  rarely  present  themselves  of  investigating  the  early 
stages  of  cancer  in  the  dead  subject ;  according  to  a  few  observations, 
fibrous  carcinoma,  when  closely  examined,  appears  to  consist  of  dense 
whitish,  retiform  fibres,  differing  from  the  normal  texture  of  the  vaginal 
portion  of  the  uterus  in  which  they  are  found,  and  in  their  very  minute 
meshes  a  pale  reddish-yellow  or  grayish  translucent  substance  is  depo- 
sited. This  morbid  growth  is  inserted  into  the  uterine  tissue  without 
well-marked  boundaries ;  it  occupies  a  various  extent,  and  from  accumu- 
lating at  certain  points,  gives  rise  to  the  irregular  nodulated  character 
and  the  well-knowTn  induration  which  accompanies  the  enlargement  of 
the  cervix. 

Medullary  cancer  in  the  first  instance  appears  as  an  infiltration  of  a 
white  lardaceo-cartilaginous  or  lax  encephaloid  matter,  in  which  the 
uterine  fibre  disappears  ;  as  the  deposit  increases  the  vaginal  portion 
assumes  an  uneven  nodulated  character,  and  appears  hard  and  elastic  to 
the  touch.  Cancer  of  the  uterus  very  rarely  presents  itself  in  the  shape 
of  isolated  globular  growths. 

As  the  cancerous  degeneration  proceeds,  and  especially  on  the  com- 
mencement of  the  stage  of  metamorphosis,  with  its  consequent  new  for- 
mations, particularly  if  they  belong  to  the  medullary  variety,  the  lower 
segment  of  the  uterus  undergoes  a  very  considerable  and  rapid  enlarge- 
ment. At  last  we  find  a  callous,  loose,  spongy  ulcer  developed  in  the 
usual  manner,  which  discharges  a  very  fetid,  greenish-brown,  sanious  and 
sanguineous  fluid,  and  as  it  extends,  generally  causes  a  progressive  infil- 
tration of  cancerous  matter.  The  tumefaction  of  the  cervix  and  the  fun- 
goid excrescences  not  unfrequently  close  up  the  orifice,  and  the  conse- 
quent enlargement  of  the  womb  will  be  the  larger,  the  more  copious  the 
secretion  of  the  mucus. 

Cancerous  degeneration  of  the  uterus  is  generally  confined,  in  a  very 
remarkable  and  distinct  manner,  to  the  vaginal  portion ;  still  there  are 
frequent  exceptions  to  this  rule,  as  the  disorganization  is  sometimes 
found  to  extend  with  great  rapidity  to  the  body,  and  even  to  the  fundus 
of  the  uterus ;  this  is  particularly  the  case  if  the  os  tincae  has  already 
been  attacked  by  ulceration.  The  disease  may  spread  downwards  and 
involve  the  vagina,  thus  establishing  vaginal  cancer.  It  may  extend  in 
other  directions,  and  thus  give  rise  to  cancerous  degeneration  of  the 
rectum,  the  bladder,  the  pelvic,  cellular,  and  adipose  tissue,  and  the 
periosteum ;  the  uterus  thus  becomes  fixed  in  the  pelvis,  and  at  last  we 
find  the  peritoneum  attacked,  cancerous  growths  being  formed  upon  it 
and  its  tissue,  or  perforating  it,  especially  in  the  shape  of  medullary 
masses. 

Cancerous  ulceration  spreads  in  the  same  direction ;  in  rare  cases  we 
find  the  greater  part  of  the  uterus,  and  even  its  fundus,  destroyed.  The 
destructive  process,  when  attacking  the  vagina,  sometimes  predominates 
on  the  anterior,  sometimes  on  the  posterior  surface  ;  sometimes  it  attacks 
both  equally,  and  may  extend  downwards  almost  to  the  external  orifice. 
It  also  involves  the  degenerated  parietes  of  the  rectum  and  of  the  blad- 
der, and  generally  produces  extensive  communications  between  their 
cavities  and  the  original  cancerous  sinus  (ulcerous  cloacae).  It  finally 
extends  in  the  shape  of  sinuous  passages,  through  the  remainder  of  the 


228  DISEASES    OF    THE    UTERUS 

cancerous  mass  that  fills  the  pelvic  cavity,  to  the  pelvic  bones.  In  this 
manner  a  large  cavity  with  fungoid  parietes  is  at  last  established,  which 
occupies  the  greater  part  of  the  uterus  and  the  vagina,  and  opens  into 
the  cavities  of  the  rectum  and  the  bladder ;  above  it  is  closed  in  by  the 
fundus  uteri  and  the  adherent  rectum  and  cervix  vaginae,  as  also  by  the 
caecum  and  small  intestine,  which  are  agglutinated  to  these  parts,  and  at 
last  it  penetrates  into  the  cavity  of  the  peritoneum  or  the  intestines. 
The  contents  of  the  cavity  are  cancerous  ichor  mixed  up  with  faecal 
matter,  urine,  and  portions  of  gangrenous  tissue. 

The  temporary  and  tumultuous  periods  of  development  presented  by 
the  peritoneal  inflammations  of  the  pelvic  and  hypogastric  regions,  which 
accompany  and  characterize  the  metamorphic  and  ulcerative  stages,  and 
which  not  unfrequently  extend  from  the  original  layer  over  the  entire 
peritoneum,  are  important  occurrences  in  the  progress  of  cancerous 
disease. 

Uterine  cancer  is,  in  most  cases,  a  primary  disease,  and  generally  re- 
mains for  a  long  time,  if  not  throughout  the  sole  carcinomatous  affection 
of  the  organism.  However,  it  is  sometimes  developed  concurrently  with 
or  consecutively  to  mammary  and  ovarian  cancer ;  or  it  is  accompanied 
by  degenerations  of  the  adjoining  tissues  above  mentioned,  and  of  the 
lymphatic  glands,  which  must  be  explained  upon  the  theory  of  propaga- 
tion by  contact ;  or  again,  it  is  associated  with  cancer  of  the  peritoneum, 
of  the  liver,  the  stomach,  and  the  breasts,  with  cancer  of  the  bones,  with 
mollities  ossium,  ovarian  cancer,  and  universal  cancerous  deposit,  as  a 
consequence  of  the  resulting  cancerous  dyscrasia. 

Uterine  cancer  most  frequently  occurs  between  the  fortieth  and  fiftieth 
year ;  still  there  are  many  cases  on  record  in  which  it  appeared  between 
the  thirtieth  and  fortieth  year,  and  even  earlier. 

The  cases  of  spontaneous  recovery  from  uterine  cancer  are  of  extreme 
rarity,  but  they  do  occur ;  the  carcinoma  and  the  cancerous  ulceration 
are  then  limited  to  the  cervix,  the  internal  orifice  forming  the  boundary ; 
the  loss  of  substance  heals  with  a  funnel-shaped  cicatrix. 

We  append  to  the  above  remarks  on  uterine  cancer  a  brief  account  of 
the  so-called — 

8.  Cauliflower  excrescence  of  the  os  uteri,  which  we  are  inclined  to 
consider  as  of  a  cancerous  nature.  It  is  of  very  rare  occurrence,  and  we 
have  only  once  observed  it  in  the  living  subject,  in  a  form  similar  to  that 
described  and  delineated  by  Clarke.  It  presented  the  appearance  of  a 
confervoid  growth,  consisting  of  lenticular,  pale  red,  transparent,  and 
tolerably  hard  corpuscles,  strung  together  like  the  beads  of  a  rosary, 
projecting  on  the  orifice  of  the  uterus  into  the  vagina,  and  bleeding  on 
the  slightest  touch.  It  was  developed  and  grew  from  an  evidently  can- 
cerous base  of  the  medullary  variety. 

Clarke  states,  that  it  also  occurs  without  this  complication,  and  that 
it  is  curable ;  the  unfrequency  of  its  occurrence  and  the  circumstance 
that  after  death  it  collapses,  and  merely  appears  like  a  slight  accumula- 
tion of  delicate  cellular  tissue,  render  it  difficult  to  decide  the  question 
as  to  its  cancerous  nature ;  this,  however,  is  the  view  we  are  inclined  to 
adopt. 

The  chief  and  very  dangerous  symptom  which  the  affection  presents 


AFTER    PARTURITION.  229 

are  frequent  exhausting  hemorrhages,  which  are  "brought  on  by  the  most 
trivial  causes.  It  is  said  to  occur  at  any  period  of  life  after  the  twentieth 
year,  but  very  rarely  before  that. 

SECT.    II. — DISEASES   OF   THE   UTERUS  AFTER    PARTURITION. 

Under  this  head  we  include  diseases  to  which  the  uterus  is  liable  in 
consequence  of  the  puerperal  state,  which  are  essentially  (in  reference 
to  causation)  connected  with  the  latter,  and  especially  with  the  concur- 
rent detachment  of  the  membranes  and  the  placenta  from  the  inner 
surface  of  the  uterus,  and  which,  for  that  reason,  must  be  termed  puer- 
peral affections.  We  pass  over  the  subjects  which  have  already  been 
discussed,  and  enter  at  once  upon  the  consideration  of  these  diseases  in 
the  following  (natural)  sequence. 

§  1.  On  defective  and  irregular  Contraction  and  Involution  of  the 
Uterus  after  Childbirth. — We  occasionally  find  that  the  uterus  presents 
a  condition  of  universal  flabbiness  or  collapse  of  its  parietes,  accompa- 
nied by  a  trifling  reduction  of  size,  which  must  be  considered  as  para- 
lysis from  exhaustion,  and  which  results  from  tedious  or  instrumental 
labor,  or  from  parturition,  the  first  stages  of  which  had  been  much  ac- 
celerated. In  other  cases,  and  they  are  of  frequent  occurrence,  we  find 
the  fundus  and  the  neighboring  parts  of  the  corpus  uteri  to  be  the  seat 
of  excessive  contraction  and  energy,  whilst  the  inferior  segment  is  in  a 
contrasting  state  of  atony  and  collapse ;  there  are  other  cases  again  in 
which  excessive  contraction  prevails  at  the  middle  of  the  uterus  forming 
a  zone  round  it,  or  at  smaller  and  less  defined  portions.  These  occur- 
rences may  be  brought  about  by  the  most  various  impediments  to  par- 
turition, by  pressure,  contusion  of  the  uterus,  apoplexy  of  the  womb 
(vide  page  217),  by  original  irregular  innervation  of  the  uterus,  &c.  As 
may  be  supposed,  they  give  rise  in  the  first  instance  to  hemorrhage,  and 
in  consequence  of  this  and  of  the  general  debility,  they  impede  the 
further  involution  of  the  uterus,  and  thus  protract  the  disposition  to 
puerperal  affections.  We  must  here  mention  a  very  singular  circum- 
stance, which  may,  on  account  of  the  consequent  danger,  become  im- 
portant, and  may  even  be  misunderstood  in  post-mortem  examinations ; 
it  is  paralysis  of  the  placental  portion  of  the  uterus,  occurring  at  the 
same  time  that  the  surrounding  parts  go  through  the  ordinary  processes 
of  reduction.  It  induces  a  very  peculiar  appearance.  The  part  which 
gave  attachment  to  the  placenta  is  forced  into  the  cavity  of  the  uterus 
by  the  contraction  of  the  surrounding  tissue,  so  as  to  project  in  the  shape 
of  a  conical  tumor,  and  a  slight  indentation  is  noticed  at  the  correspond- 
ing point  of  the  external  uterine  surface.  The  close  resemblance  of  the 
paralyzed  segment  of  the  uterus  to  a  fibrous  polypus,  may  easily  induce 
a  mistake  in  the  diagnosis,  and  nothing  but  a  minute  examination  of  the 
tissue  can  solve  the  question.  The  affection  always  causes  hemorrhage, 
which  lasts  for  several  weeks  after  childbirth,  and  proves  fatal  by  the 
consequent  exhaustion.  We  have  met  with  it  twice,  once  after  abortion, 
and  once  after  parturition  at  the  full  period.1 

1  Dr.  Betschler,  during  his  visit  to  Vienna  in  1840,  communicated  a  similar  case  to  me  as 
having  occurred  at  Breslau  ;  and  there  can  be  little  doubt  that  Dr.  Burkhardt  (vide  Berliner 
Centralzeitung,  x,  19)  speaks  of  this  condition,  under  the  title  of  acute  fungus  hitmatodea 
uteri,  as  of  a  new  and  hitherto  unknown  cause  of  flooding  after  childbirth. 


230  DISEASES    OF    THE    UTERUS 

Lastly,  we  observe  that  the  contraction  and  involution  of  the  uterus 
is  more  or  less  permanently  impaired  by  all  the  different  puerperal  in- 
flammatory processes. 

§  2.  Puerperal  Inflammations. — Puerperal  inflammations  generally, 
are  in  most  cases  of  a  very  complicated  nature,  and  it  is  of  extreme 
scientific  and  practical  importance  that  we  should  obtain  a  comprehen- 
sive sketch  of  their  anatomical  bearings,  as  well  as  an  analysis  and  cor- 
rect interpretation  of  the  constituent  phenomena.  If  we  consider  puer- 
peral inflammation  of  the  uterus  by  itself,  we  find  that  it  always  appears 
in  the  shape  of  an  exudative  process,  affecting  the  raw  exposed  surface 
of  the  uterus  to  which  the  placenta  had  been  attached ;  in  reference  to 
its  original  seat,*  it  must  therefore  always  be  considered  as  endometritis. 
We  shall  first  have  to  examine  into  the  characters  of  this  affection,  and 
then  proceed  to  investigate  other  important  puerperal  diseases ;  after 
which,  we  shall  give  a  summary  and  an  analysis  of  changes  taking  place 
in  organs  and  tissues  that  do  not  belong  to  the  original  seat  of  disease, 
and  conclude  with  a  consideration  of  the  issues  and  consequences  of 
primary  and  secondary  puerperal  affections. 

1.  Puerperal  endometritis. — This  affection,  as  has  already  been  ob- 
served, is  invariably  an  exudative  process ;  but  it  offers  the  greatest 
variety,  both  in  reference  to  the  plasticity  of  its  product  and  to  the  con- 
dition of  the  diseased  tissue,  either  in  individual  cases  or  in  entire  epi- 
demics. The  series  is  almost  endless,  but  we  may  consider  genuine 
uterine  croup  on  the  one  hand,  and  the  so-called  genuine  putrescence  of 
the  uterus  on  the  other,  as  its  extremes  ;  the  very  fact  of  this  great  mul- 
tiplicity of  forms  obliges  us  to  limit  our  descriptions  to  the  most  promi- 
nent ones. 

In  certain  cases  we  find  the  internal  surface  of  the  uterus  lined  by  a 
yellowish  or  greenish  dense  exudation,  of  greater  or  less  thickness  and 
extent,  either  in  small  patches  or  investing  the  entire  uterus,  and  either 
firmly  or  loosely  agglutinated,  and  occasionally  partially  or  entirely  de- 
tached from  the  subjacent  tissue,  so  as  to  appear  corrugated  or  plicated. 
The  uterine  mucous  membrane  under  the  lymphatic  coating  is  found  red- 
dened, tumefied,  and  slightly  softened ;  the  free  parts  are  discolored, 
and  invested  with  a  dirty  reddish  or  brownish  secretion,  and  with  rem- 
nants of  the  deciduous  membrane.  The  exudation  generally  interpene- 
trates largely  the  exposed  raw  tissue  of  the  placental  portion  of  the 
uterus,  and  causes  it  to  assume  a  peculiar  ulcerated  appearance.  This 
is  uterine  croup. 

In  other  cases  the  exuded  matter  is  a  gelatinous,  purulent,  dirty  yellow, 
loose  and  easily  detached  layer,  beneath  which  the  internal  stratum  of 
uterine  tissue  appears  spongy,  infiltrated,  soft,  and  may  be  easily  de- 
tached in  the  shape  of  a  dirty  yellowish-red,  or  partly  greenish  and 
brownish  pulp.  The  internal  surface  of  the  uterus  presents,  in  addition 
to  the  lymphatic  exudation,  a  glutinous  secretion  of  a  similar  tinge. 

Again,  the  internal  surface  of  the  uterus  may  not  present  a  trace  of 
coagulable  lymph,  but  be  invested  by  a  purulent  sanious  and  very  dis- 
colored exudation,  beneath  which  we  find  the  uterine  mucous  membrane 
infiltrated,  in  more  or  less  extensive  or  circumscribed  patches,  with  a 


AFTER    PARTURITION.  231 

similar  product ;  and  it  may  either  be  easily  removed  in  the  shape  of  a 
thin  and  much-discolored  pulp,  or  it  has  already  become  detached,  and 
is  mixed  up  with  the  contents  of  the  uterus  in  the  shape  of  friable  dis- 
colored flocculi.  In  the  place  of  the  destroyed  tissues,  we  occasionally 
discover  the  products  of  a  reactive  process,  in  the  shape  of  a  more  or 
less  consistent  sanio-purulent  secondary  exudation. 

Again,  the  internal  layer  of  uterine  tissue  may  be  covered  with  a  thin 
opaque  or  more  dense,  pale  green  or  brownish,  or  dark  chocolate  or  cof- 
fee-colored product,  beneath  which  it  is  converted,  to  a  greater  or  less 
depth,  into  a  loose,  infiltrated,  fetid  pulp,  of  a  similar  tint.  This  condi- 
tion, which  differs  from  ordinary  sphacelus,  has  been  termed  putrescence 
of  the  uterus. 

All  these  characters  point  to  an  exudative  process,  the- peculiar  nature 
of  which  is  fixed  by  the  form  of  its  product,  and  the  condition  of  the 
substratum,  and  especially  by  the  state  of  fusion  of  the  latter.  There 
are  numerous  states  of  transition  between  the  forms  described,  and  they 
not  unfrequently  become  complicated  with  one  another  in  such  a  manner 
that  a  process  of  a  malignant  nature  follows  one  that  is  accompanied  by 
a  secretion  of  plastic  lymph.  As  primary  exudative  processes,  they  are, 
if  possible,  to  be  distinguished  from  similar  secondary  processes  which 
may  occur  in  the  course  of  the  disease  in  consequence  of  a  secondary 
affection  of  the  blood,  resulting  from  inflammation  of  the  veins  or  lym- 
phatic vessels. 

As  supplementary  to  the  above,  we  have  to  examine  those  anomalies 
presented  by  the  uterus,  which  are  either  direct  reflexes  of  the  processes 
in  question,  or  which  occur  as  accidental  complications. 

To  the  former  appertain  paralysis  of  the  uterine  fibres  and  impeded 
involution  of  the  uterus  in  various  degrees.  According  as  the  puerperal 
affection  attacks  the  uterus,  sooner  or  later  after  parturition  or  with 
more  or  less  intensity,  the  womb  is  found  of  greater  or  less  size,  more 
or  less  relaxed,  collapsed,  softened ;  and  certain  portions  that  contain  a 
large  amount  of  cellular  tissue,  such  as  the  lateral  edges  and  the  cervix, 
are  infiltrated  with  a  pale  yellow,  sero-gelatinous,  or  sero-purulent  fluid. 
The  external  surface  of  the  fundus  and  body  of  the  uterus  not  unfre- 
quently exhibit  numerous  shallow  depressions,  that  are  caused  by  the 
pressure  of  adjoining  tympanitic  coils  of  intestine. 

Among  the  accidental  complications  we  reckon  sanguineous  engorge- 
ment (apoplexy)  of  the  neck  of  the  uterus,  the  superficial  or  profound 
lacerations  and  contusions  which  occur  at  this  point,  and  in  the  vaginal 
segment ;  the  lacerations  being  invested  with  exudation  of  a  more  or  less 
plastic  character,  whereas  the  contused  parts  not  unfrequently  appear 
in  a  state  of  gangrenous  solution.  We  have  to  mention  the  sloughs  of 
greater  or  less  dimensions,  which  occur  chiefly  at  the  neck  and  vaginal 
portion  of  the  uterus,  and  also  in  the  vagina  and  the  external  genitals, 
in  company  with  malignant  exudative  processes.  These  processes  lead 
to  ulceration  and  gangrenous  fusion  of  the  tissues,  very  often  inducing 
extensive  loss  of  substance  in  the  external  sexual  organs  and  the  neigh- 
boring parts  ;  they  render  the  prognosis  of  the  individual  case  very  un- 
favorable, both  on  account  of  the  character  of  the  original  affection,  as 
well  as  of  the  consecutive  destruction  which  they  entail. 


232  DISEASES    OF    THE    UTERUS 

Notwithstanding  its  close  relation  to  the  processes  of  exudation  and 
fusion,  which  we  have  hitherto  investigated,  we  think  it  necessary,  on 
account  of  the  novelty  and  scientific  interest  attached  to  the  question,  to 
devote  a  separate  consideration  to  the  dysenteric  process  occurring  in 
the  uterus  after  childbirth,  or  puerperal  uterine  dysentery. 

The  appearance  presented  by  the  inner  surface  of  the  uterus  varies 
according  to  the  intensity  of  the  disease.  In  one  case  it  is  uneven, 
nodulated,  and  invested  by  a  dirty  reddish,  or  brownish  fetid  secretion  ;  the 
projecting  parts  of  the  mucous  membrane  are  covered  with  a  grayish- 
yellow  or  firm  greenish  exudation,  which  here  and  there  presents  a  fur- 
furaceous  exfoliation,  and  the  subjacent  mucous  membrane  itself  is  gene- 
rally converted  into  a  yellow  slough ;  the  entire  surface  may  thus  in  the 
advanced  degrees  present  an  appearance  exactly  resembling  the  impeti- 
ginous  condition  of  the  intestine  in  dysentery.  The  tissues  of  the  uterus 
are  infiltrated  throughout  with  serum,  and,  as  in  the  intestine,  we  find 
the  projections  to  be  more  particularly  owing  to  an  accumulation  of  the 
serous  fluid  at  certain  points.  In  another  and  more  advanced  degree, 
which  always  runs  a  very  rapid  course,  the  internal  layer  of  the  uterus 
is  found  degenerated  into  a  brownish-black,  friable,  loose  or  detached 
mass ;  the  uterine  cavity  contains  a  fetid  matter  resembling  coffee- 
grounds  ;  the  uterine  tissue  is  flabby,  pale,  discolored,  and  more  or  less 
infiltrated  with  the  sanious  matter.  The  process  may  thus  be  said  to 
represent  essentially,  what  we  must  call,  if  consistent  in  our  terminology, 
dysenteric  putrescency  of  the  uterus. 

The  uterus  in  this  case  is  always  very  large,  or,  in  other  words,  its  in- 
volution is  eminently  retarded. 

It  is  an  additional  evidence  of  the  nature  of  this  affection  that  it  is 
often  seen  combined  with  true  dysentery,  or  with  the  dysenteric  process 
on  the  mucous  membrane  of  the  colon.  The  puerperal  diseases  occurring 
during  the  prevalence  of  a  dysenteric  epidemic  therefore  deserve  a  more 
careful  examination  and  appreciation  in  reference  to  this  point,  both  at 
the  bedside  and  in  the  dead-room. 

These  processes  are  scarcely  ever  isolated,  but  are  almost  invariably 
complicated  with  others.  The  degree  of  connection  existing  between 
them  and  the  complications,  and  between  the  complications  themselves, 
differs  very  much ;  we  shall  consider  these  points  more  fully,  as  we  are 
about  to  examine  the  more  important  of  these  processes  separately. 

2.  Inflammation  of  the  veins  and  lymphatics  of  the  uterus. — Both,  but 
especially  phlebitis,  are  important  puerperal  diseases. 

Uterine  phlebitis  is  generally  a  primary  affection,  originating  in  the 
open  mouths  of  the  veins  at  the  insertion  of  the  placenta,  and  caused  as 
well  by  their  laceration  as  by  contact  with  the  external  atmosphere,  with 
the  traumatic  secretion  of  the  part,  and  with  the  product  of  exudation  on 
the  internal  surface  of  the  uterus.  It  is  either  confined  to  a  small  portion 
of  the  veins,  or  it  spreads  over  the  greater  part  of  the  veins  of  the  uterus 
belonging  to  the  spermatic  or  uterine  system  of  vessels.  In  the  latter 
case,  a  secondary  inflammation  of  the  trunk  of  the  spermatic  vein,  brought 
on  by  coagulation  of  the  blood,  may  on  the  one  hand  extend  through  the 
vena  cava  to  the  right  auricle,  or  on  the  other  along  the  iliac  and  the 


AFTER    PARTURITION.  233 

crural  veins,  to  the  cutaneous  veins  of  the  lower  extremity  ;  in  this  case 
the  symptoms  of  phlegmasia  alba  dolens  are  induced. 

The  resulting  products  differ  very  much.  There  is  no  doubt  that 
coagulable  lymph  is  frequently  secreted,  which  causes  the  venous  parietes 
to  become  agglutinated  to  one  another,  or  to  a  contracting  plug  of 
coagulum  ;  but  in  most  cases  pus  is  formed,  which  is  variously  discolored, 
presents  a  dirty  geenish,  or  brownish,  or  chocolate-colored  hue,  with 
a  fetid  odor,  varies  in  density,  and  is  more  or  less  sanious  (septic  phle- 
bitis). In  consequence  of  exacerbations,  the  same  portions,  or,  if  the 
disease  extends,  consecutive  sections  of  the  uterine  venous  system,  may 
present  various  exudations  at  the  same  time  or  in  succession. 

Metrophlebitis  undoubtedly  sometimes  occurs  as  the  sole  and  primary 
disease,  but  in  the  vast  majority  of  cases  it  is  complicated  with  exuda- 
tive processes  on  the  internal  surface  of  the  uterus.  This  combination 
commonly  takes  place  from  the  commencement,  or  the  phlebitis  super- 
venes upon  and  is  induced  by  the  exudative  process  ;  or,  lastly,  phlebitis 
may  exist  for  a  short  period  in  an  isolated  form  as  the  primary  disease, 
and  give  rise  to  a  single  or  to  repeated  exudative  processes. 

We  thus  find  that  the  combined  processes  are  closely  related  to  one 
another,  in  reference  to  their  essential  characters  and  the  nature  of  their 
product ;  this  and  other  points  will  become  more  apparent  from  the  de- 
scription of  the  chief  anatomical  symptoms  which  we  are  about  to  give. 

If  incisions  be  made  in  various  directions  from  the  point  of  insertion 
of  the  placenta,  to  the  lateral  parietes  of  the  uterus  and  the  adjoining 
broad  ligaments,  a  large  number  of  veins  become  apparent,  which  are 
dilated  and  varicose,  and  filled  with  yellow  or  greenish-yellow  viscid  pus, 
or  even  with  chocolate-colored  sanies.  Their  orifices  at  the  placental 
portion  of  the  uterus,  are  either  closed  up  by  loose  pale  coagula,  or  they 
are  covered  over  with  an  exudation  which  attaches  itself  to  the  spongy 
tissue  of  the  raw  surface,  or,  lastly,  they  are  exposed  so  that  their  con- 
tents exude  on  the  application  of  a  slight  pressure.  The  coats  of  the 
veins  are  relaxed  and  pale,  the  lining  membrane  is  opaque,  and  dis- 
colored by  the  contents  of  the  vessels,  and  after  a  protracted  duration  of 
the  disease,  it  appears  tumefied,  thickened,  partially  gangrenous  and 
ichorous.  The  tissue  surrounding  the  veins,  and  especially  the  cellu- 
lar tissue  at  the  lateral  portions  of  the  uterus,  is  infiltrated  with  a 
yellow  gelatinous  or  purulent  matter,  which  is  much  discolored  if  the  con- 
tents of  the  veins  are  ichorous ;  the  tissue  is  relaxed,  soft,  friable,  and 
lacerable.  At  different  points  there  are  abscesses  of  greater  or  less  di- 
mensions, which  not  unfrequently  burst  internally,  and  discharge  their 
contents  into  the  uterus. 

The  internal  surface  of  the  uterus  presents  purulent  and  ichorous 
exudations,  the  products  of  primary  or  secondary  processes,  or  of  both. 
The  tissues  throughout  are  in  a  state  of  disorganization  or  putrescence, 
becoming  dissolved  in  a  manner  analogous  to  the  exuded  product,  and 
being  attacked  from  the  various  foci  of  destruction  within  the  parietes  of 
the  uterus  themselves.  The  discoloration  advances  as  far  as  the  perito- 
neum, and  the  affection  may,  therefore,  be  recognized  by  the  external 
appearance,  as  well  as  by  the  general  habit  of  the  organ.  The  fusion 
occasionally  predominates  at  one  portion  of  the  placental  segment  of  the 


234  DISEASES    OF    THE    UTERUS 

uterus,  involves  the  entire  thickness  of  the  parietes,  and  causes  the  por- 
tion to  be  detached,  and  to  pass  into  the  uterine  cavity  in  the  shape  of  a 
pulpy,  discolored,  semifluid  plug. 

Uterine  phlebitis  often  runs  a  rapid  course,  with  intense  typhoid 
symptoms,  proving  fatal  by  uterine  paralysis  ;  or  it  proceeds  more  slowly 
under  circumstances  preventing  a  general  infection  of  the  blood,  even 
when  the  product  is  of  a  putrid  character,  and  then  proves  fatal  by  the 
secondary  destruction  set  up. 

Inflammation  of  the  uterine  lymphatics  is,  on  the  whole,  less  frequent 
than  phlebitis,  and  is  generally  complicated  with  the  latter.  When  it 
occurs,  the  lymphatics,  and  particularly  those  of  the  lateral  and  posterior 
portions  of  the  uterus,  of  the  ovary,  and  the  Fallopian  tubes,  become  di- 
lated and  varicose,  their  coats  pale  and  opaque,  the  lining  membrane  dull 
and  furred,  and  they  contain  a  yellow,  yellowish-green,  purulent  fluid. 
By  these  characters  they  may  be  traced  into  the  neighboring  hypogas- 
tric  and  lumbar  plexuses,  and  into  the  associated  glands,  of  the  lympha- 
tic system. 

Inflammation  of  the  veins  and  lymphatics  of  the  uterus  is  generally 
the  source  of  secondary  occurrences,  the  so-called  metastases,  or  lobular 
foci  of  inflammation  (lobulare  Entzundungsheerde),  in  the  most  various 
tissues  and  organs,  as  well  as  of  exudative  processes  occurring  in  serous 
and  mucous  membranes  during  the  later  stages  of  puerperal  disease. 

3.  Inflammation  of  the  peritoneum  (peritonitis  puer per  alis),  vieivedin 
connection  with  puerperal  inflammations  of  other  serous  membranes. — 
Peritonitis  is  known  as  a  very  common  puerperal  disease ;  in  rare  cases 
it  actually  constitutes  the  original  (primary)  puerperal  exudative  process, 
and  as  such  remains  isolated.  It  more  frequently  simulates  this  form, 
inasmuch  as  the  processes  with  which  it  was  originally  complicated  have 
become  retrograde  or  imperceptible,  or  have  actually  ceased  after  the 
discharge  of  their  products  has  been  eifected.  We  most  frequently  find 
it  complicated  with  the  puerperal  affections  already  examined — viz.  with 
the  exudative  processes  occurring  on  the  internal  surface  of  the  uterus, 
with  metrophlebitis  and  inflammation  of  the  uterine  lymphatics.  The 
pathogenetic  relations  of  puerperal  peritonitis,  and  especially  its  relations 
to  the  last-mentioned  puerperal  processes,  have  been  much  discussed,  but 
the  subject  has  not  as  yet  been  adequately  elucidated. 

We  commence  with  a  statement  of  the  anatomical  signs  presented  by 
puerperal  peritonitis,  in  reference  to  its  extent  and  terminations,  the 
quantity  and  quality  of  the  effusion,  and  the  coexistent  degree  of  redden- 
ing and  vascular  development. 

Puerperal  peritonitis  is  not  unfrequently  limited  to  the  peritoneal 
covering  of  the  uterus  and  its  appendages,  when  it  presents  more  or  less 
redness,  with  more  or  less  distinct  congestion  and  a  thin  partial  lymphatic 
exudation,  or  a  more  dense  and  extensive  layer  of  a  viscid  and  consistent 
or  loose  and  fluid  secretion. 

We  not  only  find  the  peritoneal  covering  of  the  internal  sexual  organs 
attacked  in  this  way,  but  also  the  peritoneum  of  the  entire  hypogastric 
abdominal  region.  The  disease  may  even  spread  over  the  whole  parietal 
and  intestinal  peritoneal  laminae ;  the  symptoms,  however,  at  the  same 
time  predominating  on  the  peritoneum  of  the  internal  sexual  and  adjoin- 
ing organs. 


AFTER    PARTURITION.  235 

The  entire  peritoneum  is  often  uniformly  involved  in  the  disease,  not 
only  without  any  predominance  of  the  symptoms  in  the  sexual  organs, 
but  sometimes  even  with  an  apparent  subordination  of  these  symptoms. 

The  products  of  these  processes  vary  very  much  ;  they  may  be  firm, 
yellowish-gray  concretions,  loose,  yellowish,  membranous,  grumous,  gela- 
tinous, or  fibrinous  coagula,  which  glue  the  intestines  to  one  another,  or 
to  the  parietes  of  the  abdomen,  or  they  may  be  yellow  and  greenish-yellow, 
thin,  sero-purulent  or  thick  purulent,  dirty  green  and  brownish,  red, 
hemorrhagic,  thin,  opaque,  sanious  effusions,  the  result  of  septic  periton- 
itis. The  product  is  sometimes  very  limited  in  amount,  and  may  merely 
present  a  thin  covering  of  the  internal  sexual  organs,  or  a  few  membranous 
or  fibrinous  flocculi  of  coagulable  lymph,  scattered  through  the  abdominal 
cavity  ;  but  in  the  case  of  universal  peritonitis  it  is  generally  extremely 
copious,  whatever  the  particular  variety  of  the  product. 

The  vascular  development  and  redness  is,  especially  in  the  last-named 
cases,  very  slight,  and  bears  a  marked  disproportion  to  the  quantity  of 
the  exudation. 

This  fact  in  itself,  and  more  particularly  when  examined  in  connection 
with  combined  processes  occurring  in  the  uterus,  and  numerous  analogies 
and  observations  made  at  the  bedside,  justify  the  views  we  are  about  to 
propound,  relative  to  the  genesis  of  puerperal  peritonitis  and  its  connec- 
tion with  puerperal  processes  in  the  uterus. 

Puerperal  peritonitis  not  unfrequently  arises  by  mere  contiguity  of 
tissue,  from  an  exudative  process  affecting  the  internal  surface  of  the 
uterus,  or  from  metrophlebitis.  It  may  remain  confined  to  the  internal 
sexual  organs,  or  become  generally  diffused,  and  this  occurs  the  more 
frequently  the  more  the  following  circumstance  prevails. 

The  disease  is  often,  and  even  generally,  the  result  of  a  primary  con- 
dition of  the  blood  of  the  female  which  predisposes  to  exudative  processes, 
and  is  totally  distinct  from  the  physiological  tendencies  of  the  blood  during 
pregnancy.  This  proclivity  is  evidenced  by  exudative  processes  on  the 
mucous  membrane  of  the  uterus,  the  intestine,  and  various  serous  mem- 
branes, by  exanthematic  processes  on  the  superficial  integuments,  by  a 
revival  of  tubercular  disease,  &c. ;  and  both  epidemic  and  endemic  influences 
and  individual  causes  give  it  a  peculiar  character  which  becomes  appa- 
rent in  the  product. 

Under  such  conditions  peritonitis  will  be  the  more  liable  to  arise,  the 
more  the  peritoneum  has  suffered  by  the  revolutions  in  its  local  relations 
during  parturition,  by  the  excitement  of  the  large  organ,  the  uterus,  which 
it  invests,  and  by  the  concurrent  disturbances  in  the  circulation ;  the 
more  exudative  processes,  or  metrophlebitis,  and  various  reactions  conse- 
quent upon  uterine  lesions  occur  in  the  vicinity  of  the  peritoneum,  and 
especially  in  the  uterine  mucous  membrane  ;  the  more  the  peritoneum  has 
been  previously  affected  by  the  contiguity  of  tissue  to  the  internal  sexual 
organs. 

In  this  case  peritonitis  is  a  primary  disease,  and  is  either  the  first  and 
not  unfrequently  the  only  puerperal  affection,  or  it  occurs,  as  is  more 
frequently  the  case,  concurrently  with  an  exudative  process  of  the  uterine 
mucous  membrane,  or  soon  becomes  associated  with  the  latter ;  it  inva- 
riably takes  its  origin  in  the  above-mentioned  predisposition  existing  in 
the  blood. 


236  DISEASES     OF    THE    UTERUS 

Like  other  exudative  processes  that  occur  simultaneously  or  consecu- 
tively, we  also  find  that  peritonitis  is  often  the  result  of  a  secondary  dis- 
organization of  the  blood,  caused  by  the  absorption  of  the  products  of 
exudation  upon  the  external  surface  of  the  uterus,  or  by  the  direct  ad- 
mixture of  the  products  of  metrophlebitis  with  the  blood.  In  this  case 
it  presents  the  characters  of  a  secondary  inflammation,  and  is  commonly 
complicated  with  exudative  processes  on  other  serous,  synovial,  and 
mucous  membranes,  and  with  capillary  phlebitis  in  the  most  different 
organs  and  tissues,  the  so-called  lobular  infarctions  (Lobular-Infarcte) 
and  abscesses. 

The  products  of  the  peritoneal  inflammation  in  either  case  correspond 
in  character  with  those  of  the  exudative  processes  affecting  the  internal 
surface  of  the  uterus  and  of  metrophlebitis,  whether  they  occur  simulta- 
neously, or  whether  they  precede  the  former. 

Puerperal  peritonitis  is  developed  with  more  or  less  rapidity,  and  in 
the  majority  of  cases  proves  fatal  by  inducing  abdominal  paralysis ;  or  it 
leaves  various  morbid  sequelae.  Those  exudative  processes  are  remark- 
able which  result  from  a  very  rapid  disorganization  of  the  blood,  and 
prove  fatal  within  a  few  hours,  or  within  two  to  three  days,  and  are  ac- 
companied by  paralysis  and  collapse,  affecting  the  uterus  immediately 
after  parturition,  and  by  a  sanguineous  ill-looking  effusion. 

Puerperal  peritonitis,  as  may  be  gathered  from  the  above,  is  almost 
always  remarkable  for  its  very  exudative,  or  croupy,  character. 

4.  Puerperal  inflammation  of  the  ovaries  and  Fallopian  tubes. — We 
shall  examine  these  affections  when  we  speak  of  the  diseases  of  the  respec- 
tive organs.     The  first  is  always  complicated  with  one  of  the  processes 
that  have  been  just  discussed,  and  probably  always  with  an  exudative  pro- 
cess on  the  inner  surface  of  the  uterus  ;  the  affection  of  the  Fallopian  tubes 
is  invariably  the  result  of  an  extension  of  the  uterine  exudative  process. 

5.  Phlegmasia  alba  dolens  (sparganosis}. — Various  theories  have  been 
formed  in  reference  to  this  disease  of  the  puerperal  state,  from  its  symp- 
toms in  the  living  subject ;  and  very  different  views  have  been  even  pro- 
pagated with  regard  to  its  anatomical  relations.     The  ancient  and  modern 
dicta  that  were  based  upon  anatomical  investigations  may  almost  all  be 
viewed  as  the  result  of  preconceived  notions,  and  of  examinations,  under- 
taken with  a  view  to  establish  favorite  theories,  or  conducted  without  the 
necessary  distinction  between    essential   and    accidental   circumstances 
being  observed.     It  is  only  of  late  that  the  subject  has  been  examined  in 
the  dead  body  with  an  unprejudiced  and  discriminating  judgment,  and 
that  an  anatomical  basis  has  been  obtained,  which,  though  it  may  not  be 
applicable  to  all  conditions  that  are  included  under  the  head  of  phlegma- 
sia  alba  dolens,  and  though  it  may  not  always  have  been  properly  inter- 
preted, still  appears  to  afford  sufficient  security. 

Two  lesions  seem  to  be  essentially  connected  with  this  affection.  It 
either  depends  upon  an  inflammation  of  the  veins  of  the  inferior  extremity, 
and  especially  of  the  crural  vein,  or  upon  an  inflammation  of  the  cellular 
tissue,  which  gives  rise  to  the  most  various  products.  The  latter  form  is 
particularly  likely  to  cause  the  characteristic  symptoms  which  a  so-called 
sero-lymphatic  or  sero-purulent  product,  i.  e.  fibrinous  or  purulent  exuda- 
tion diluted  by  a  large  amount  of  serum,  induces.  It  is  characterized 


AFTER    PARTURITION.  237 

by  very  slight  reddening  and  vascularity,  and  must  be  considered  as  an 
exudative  process.  In  this  shape  it  often  extends  to  the  crural  fascia, 
the  neurilemma,  the  lymphatic  vessels,  and  is  sometimes  complicated 
with  exudations  in  the  synovial  capsules  of  the  knee  and  the  hip-joint. 
As  we  have  already  observed,  it  gives  rise  to  the  most  various  products, 
and  terminates  accordingly  in  tedious  oedema,  in  sclerosis,  suppurative 
fusion,  and  gangrenous  destruction  of  the  cellular  tissue.  It  proceeds 
from  a  primary  or  secondary  dyscrasia  of  the  female,  and  is  in  either 
case  generally  combined  with  various  other  puerperal  processes.  This 
form  of  phlegmasia  alba  may,  like  the  one  that  originates  in  phlebitis, 
occur,  if  similar  causes  prevail,  independently  of  the  puerperal  state,  in 
unmarried  women  and  men  ;  and  we  find  this  to  be  particularly  the  case 
as  a  result  of  exanthematic  and  typhous  processes,  of  the  most  various 
exudative  processes,  of  cholera,  dysentery,  inflammation  of  the  lining 
membrane  of  the  vessels,  of  endocarditis,  &c.  The  disease  may  attack 
the  upper  extremities  and  even  the  trunk,  though  in  the  puerperal  state  it 
generally  affects  the  lower  extremities.  It  occasionally  proves  fatal  by 
its  sequelae,  but  more  frequently  by  the  associated  puerperal  processes. 
Crural  phlebitis  generally  passes  from  the  uterine  to  the  internal  iliac 
vein,  and  either  attacks  the  deep-seated  or  superficial  veins,  or  both. 
An  inflammation  of  the  lymphatic  vessels  is  often  superadded. 

Summary  of  the  Anomalies  in  other  Organs,  accompanying  the  above- 
described  processes. 

Besides  the  changes  which  occur  in  the  original  seats  of  the  puerperal 
processes  hitherto  examined,  there  are  so  many,  important,  and  various 
anomalies  in  other  organs  and  tissues,  that  it  is  not  sufficient  merely  to 
give  a  supplementary  account  of  the  anatomical  results,  but  that  as 
copious  an  explanation  of  them  as  possible,  becomes  necessary.  We 
shall,  in  the  first  instance,  describe  and  account  for  the  general  appear- 
ance of  the  body,  and  the  individual  organs,  and  then  arrange  the  sepa- 
rate morbid  processes  as  much  as  possible  in  groups,  according  to  their 
mutual  resemblance. 

The  dead  subject  presents  a  remarkable  disfiguration  of  the  counte- 
nance, tumefaction  and  discoloration  of  the  external  genitals,  excoriation, 
ulcerative  destruction  of  various  characters,  with  or  without  laceration 
of  the  perineum,  various  vaginal  discharges,  tympanitic  distension  of  the 
abdomen,  a  livid  erythema  of  the  common  integument  at  different  parts 
of  the  body,  white  and  often  large  coalescing  miliary  vesicles  on  the 
thorax  and  abdomen.  Yellow,  greenish,  bilious,  feculent,  chocolate- 
colored  fluids  escape  from  the  mouth. 

The  abdomen  presents,  in  most  cases,  even  if  the  peritoneal  inflamma- 
tion has  been  slight  or  entirely  absent,  a  tympanitic  distension  of  the  in- 
testines ;  this  symptom  is  most  developed  in  universal  peritonitis ;  the 
entire  intestine  is  then  so  much  distended  by  gases,  that  it  causes  im- 
pressions upon  the  uterus,  and  forces  the  epigastric  contents  of  the  ab- 
domen into  the  cavity  of  the  diaphragm,  and  with  the  latter  into  the 
thorax  as  far  as  the  fourth  and  third  ribs.  The  firmer  the  exuded  (plastic) 


238  DISEASES    OF    THE    UTERUS 

matter,  the  more  firmly  the  intestinal  coils  and  the  other  abdominal 
organs  are  agglutinated  to  one  another  and  to  neighboring  organs.  The 
coagulable  lymph  is  chiefly  contained  in  the  lower  segment  of  the  ab- 
dominal and  pelvic  cavity,  but  also  in  the  lateral  parts,  of  the  abdomen, 
between  the  mesenteries  and  in  the  vicinity  of  the  large  epigastric  viscera, 
within  spaces  that  have  become  more  or  less  circumscribed  by  the  adhe- 
sions. It  not  unfrequently  causes,  especially  on  the  surface  of  the  liver, 
shallow  depressions,  and  gives  to  the  superficial  layer  of  this  organ,  if  of 
a  purulent  and  sanious  character,  a  greenish,  and  to  the  spleen  a  black- 
ish, tinge.  The  reddening  and  vascularity  of  the  peritoneum  are  gene- 
rally inconsiderable ;  but  most  evident  at  those  parts,  which  are  free 
from  pressure,  and  take  the  form  of  narrower  or  broader  striae.  The 
membranes  of  the  intestinal  canal  are  all  tumefied,  the  interstitial  cellu- 
lar tissue  infiltrated,  the  layers  easily  distinguishable  and  lacerable.  The 
intestine  generally  contains,  in  addition  to  a  large  quantity  of  gas,  a 
yellow,  serous,  feculent  fluid,  which  mounts  up  to  the  duodenum  and 
stomach.  This  fluid  is  in  part  the  product  of  an  exudative  process  that 
occurs  in  the  greater  part  of  the  intestinal  mucous  membrane,  and  which 
we  shall  have  occasion  subsequently  to  examine  more  closely.  The  duo- 
denum and  the  stomach  may  also  be  found  to  contain  a  copious  amount 
of  yellowish-green  or  intensly  green  biliary  fluid. 

We  have  here  to  advert  briefly  to  two  symptoms  that  occur  during  the 
course  of  puerperal  peritonitis,  and  which  not  unfrequently  coexist — 
they  are,  vomiting  of  the  biliary  matters  contained  in  the  duodenum  and 
the  stomach,  and  of  the  sero-feculent  matters  that  rise  from  the  intestine, 
and  diarrhoea.  The  former  is  to  be  explained  by  the  paralysis  of  the 
muscular  coat  of  the  intestine,  caused  by  the  peritoneal  exudative  pro- 
cess, and  the  fixation  of  the  intestine  by  plastic  exudations ;  it  com- 
mences at  the  duodenum  and  the  stomach,  the  peritoneal  covering  of 
which  generally  remains  unattached.  The  latter  is  caused  by  the  exudative 
process,  and  the  consequent  irritation  of  the  intestinal  muscular  coat, 
which  forms  a  counterpoise  to,  and  even  counteracts,  the  paralysis  at 
some  points ;  it  is  the  more  frequent  and  the  more  considerable  the  less 
marked  the  paralyzing  influence  of  the  peritoneal  affection  is. 

Almost  all  organs  appear  in  a  state  of  relaxation,  which  is  proportioned 
to  the  primary  or  secondary  dyscrasia  of  the  blood,  and  to  the  extent  in 
which  the  blood  has  become  deprived  of  its  fibrine  by  the  fibrinous  exu- 
dations caused  by  inflammations  of  the  peritoneum,  the  pleura,  &c.  It 
is  owing  to  a  moistening  or  imbibition  of  the  tissues  with  the  attenuated 
serum  of  the  blood,  which  easily  exudes  through  the  vascular  coats,  and 
is  for  the  same  reason  coupled  with  pallor  or  discoloration,  owing  to  the 
coloring  matter  which  adheres  to  the  serum.  In  the  abdomen  we  find 
that  the  kidneys  and  the  liver  are  chiefly  distinguished  by  the  softening, 
pallor,  or  pale  red  discoloration,  oedema  and  imbibition,  relaxation  and 
friability  of  their  tissues.  In  the  thoracic  cavity,  the  lungs  are  chiefly 
affected  by  these  and  similar  deviations ;  the  muscular  portion  of  the 
heart,  too,  is,  like  the  other  muscles,  and  especially  those  that  are  in- 
volved in  the  peritoneal  inflammatory  process,  soft,  pale,  moist,  and 
lacerable.  All  the  serous  membranes  and  the  lining  membrane  of  the 
vessels  are  infiltrated  with  serosity,  and  are  more  or  less  reddened,  and 


AFTER    PARTURITION.  239 

the  serous  cavities  contain  various  quantities  of  a  transuded,  pale  or  dark- 
red  serum.  The  brain  alone,  as  in  numerous  other  allied  processes, 
e.  g.  in  typhus,  forms  an  exception,  inasmuch  as  it  appears  denser  and 
harder,  drier  and  paler,  than  usual. 

The  spleen  is  very^frequently,  though  not  always,  tumefied ;  it  is  so 
particularly  in  secondary  disease  of  the  blood,  whether  or  not  accom- 
panied by  the  secondary  processes  (deposits),  that  we  shall  subsequently 
have  to  notice. 

The  lungs  are  reduced  in  size,  and  denser,  in  consequence  of  the  up- 
ward pressure  exerted  by  the  contents  of  the  abdomen ;  their  inferior 
lobes  are  of  a  dark  purple  color,  and  in  a  condition  of  passive  hypersemia. 

We  now  proceed  to  enumerate  the  separate  morbid  processes  in  the 
different  organs,  and  to  point  out  their  relations  to  the  original  puerperal 
disease. 

Our  first  attention  is  due  to  the  exudative  processes  on  the  various 
mucous  and  serous  membranes.  That  affecting  the  intestinal  mucous 
membrane  is  of  particular  importance.  The  entire  tract  is  generally 
involved;  it  is  but  slightly  reddened,  and  commonly  exhibits  a  thin, 
watery,  serous,  or  viscid  gelatinous,  or  gelatino-purulent  or  genuine 
purulent  product ;  the  tissue  fuses,  and  the  submucous  cellular  tissue  is 
more  or  less  infiltrated.  In  this  manner  the  diarrhoeas  of  the  puerperal 
state  are  established.  The  exudation  is  rarely  of  a  firm,  fibrinous,  or 
croupy  nature,  but  most  commonly  its  serous  character  predominates, 
and  this  is  the  more  the  case  the  larger  or  more  fibrinous  the  product, 
resulting  from  the  coexistent  attack  of  peritonitis.  In  certain  cases  the 
process  that  takes  place  on  the  mucous  membrane  of  the  colon  assumes 
a  dysenteric  type,  and  as  in  the  above-named  forms,  corresponds  to  the 
exudation  upon  the  internal  surface  of  the  uterus  or  to  the  product  of 
metrophlebitis.  Similar  processes,  though  generally  accompanied  with 
a  coagulable  product,  are  occasionally  discovered  upon  the  mucous  mem- 
brane of  the  stomach,  the  oesophagus,  and  the  bladder,  and  in  the  lungs 
in  the  shape  of  (partial)  aphthous  pneumonia ;  this  is  chiefly  the  case 
when  the  blood  has  not  been  exhausted  of  its  fibrine. 

Among  the  exudative  processes  that  take  place  on  serous  membranes, 
the  most  frequent,  after  that  occurring  on  the  peritoneum,  is  pleuritis, 
which  is  often  coexistent  with  peritonitis  ;  pericarditis  is  of  less  frequent 
occurrence.  We  also  meet  with  exudations  in  the  synovial  bursse,  and 
especially  in  that  of  the  knee-joint,  the  sterno-clavicular  and  humoral 
articulations,  and,  lastly,  in  the  capsule  of  the  humor  aqueus.  The  exu- 
dations are  generally  very  copious,  fibrinous,  and  purulent.  A  thin  soft 
exudation  is  often  found  upon  the  dura  mater,  accompanied  by  a  slight 
reddening  of  the  latter. 

All  these  processes  may  be  variously  combined,  and  they  are  depen- 
dent upon  the  primary  or  secondary  disorganization  of  the  blood,  and 
especially  upon  that  caused  by  the  absorption  of  pus  in  metrophlebitis. 

Next  in  order  come  the  processes  dependent  upon  secondary  phlebitis 
of  the  larger  veins,  and  of  the  capillary  venous  systems  of  various  organs 
and  tissues. 

The  former  are  generally  developed  in  the  vicinity  of  the  original  mor- 
bid affection,  as  in  the  plexus  pampiniformis,  the  trunk  of  the  internal 


240  DISEASES    OF    THE     UTERUS 

spermatic  vein,  the  internal  iliac  and  crural  veins ;  though  they  frequently, 
too,  are  generated  at  a  distance,  as  in  the  cerebral  sinuses  and  the  pul- 
monary artery.  These  give  rise  to  the  so-called  metastases  or  lobular 
abscesses,  which  we  shall  now  proceed  to  examine. 

We  often  find  larger  or  smaller  circumscribed  spots  in  the  most  various 
organs  and  tissues ;  the  dark-red  points  of  congestion,  or  small  accumula- 
tions of  pus  or  sanies,  which  we  have  repeatedly  adverted  to.  They  are 
remarkably  frequent  and  numerous  in  the  organs  of  sanguification,  espe- 
cially in  the  lungs  and  the  spleen ;  they  are  next  seen  in  the  kidneys,  and 
more  rarely  in  the  liver ;  they  are  occasionally  met  with  in  the  brain,  in 
the  thyroid  and  parotid  glands ;  in  all  muscles,  particularly  in  the  heart ; 
in  fibrous  tissues,  as  in  the  dura  mater  and  the  periosteum.  Again,  they  are 
very  common  in  the  mucous  tissue,  especially  of  the  bladder  and  the  in- 
testines ;  they  occur  throughout  the  cellular  tissue,  but  they  seem  to  pre- 
dominate in  the  cellular  tissue  of  the  extremities,  of  the  mediastina,  of 
the  neck,  the  iliac  muscles,  and  the  intestines  and  stomach. 

We  have  already  demonstrated  that  these  processes  are  either  genuine 
exudative  processes,  or  that  they  consist  in  a  coagulation  of  the  blood 
within  the  capillaries  (capillary  phlebitis).  In  the  latter  case  the  coagu- 
lum  fuses  in  a  manner  corresponding  to  the  disease  of  the  blood,  and  to 
the  deleterious  matter  absorbed  into  the  blood,  and  forms  a  purulent  sani- 
ous  fluid  or  gangrenous  pulp  (metastasis  puerpcralis  septica). 

They  may  probably  be  invariably  considered  as  the  result  of  a  secon- 
dary infection  of  the  blood,  of  a  poisoning  of  the  blood  by  the  introduc- 
tion of  some  product  from  the  original  nidus  of  disease,  and  particularly 
of  venous  pus  and  sanies  in  metrophlebitis.  They  consequently  always 
give  rise  to  purulent  and  sanious  products,  and  terminate  fatally  as  capil- 
lary phlebitis.  They  enter  into  various  combinations  with  one  another, 
and  with  the  exudative  processes  occurring  upon  serous  and  mucous  mem- 
branes. Owing  to  their  position  at  the  surface  of  the  organs,  we  always 
find  that  pleurisy  supervenes  upon  their  occurrence  in  the  lungs,  and 
peritonitis  upon  their  deposition  in  the  spleen. 

A  black  softening  of  the  mucous  membrane  of  the  fundus  ventriculi, 
or  of  the  oesophagus,  or  of  both  at  the  same  time,  which  is  indicated  dur- 
ing life  by  the  vomiting  of  black  coffee-grounds-like  matter,  is  of  frequent 
occurrence.  It  not  rarely  reaches  that  degree  of  intensity,  that  the  fun- 
dus of  the  stomach,  and  sometimes  the  diaphragm  also,  and  the  oesopha- 
gus, with  the  adjoining  cellular  tissue  and  mediastinum,  are  ruptured,  and 
the  fluid  that  would  have  been  evacuated  by  the  mouth  is  effused  into  the 
abdominal  or  thoracic  (especially  the  left)  cavities. 

After  difficult  labor,  the  cartilages  of  the  pelvic  synchondroses  are 
liable  to  inflammation,  in  consequence  of  the  traction  exerted  upon  them, 
and  if  the  blood  has  assumed  a  septic  constitution,  the  inflammation 
may  terminate  in  gangrenous  fusion  of  the  cartilage,  the  latter  being  con- 
verted into  a  dirty  brown  and  very  much  discolored  fluid,  contained  within 
the  investing  ligamentous  tissue. 

The  blood  contained  in  the  cavities  and  larger  vessels  presents  various 
and  more  or  less  evident  changes.  Its  fibrine  may  be  converted  into  con- 
sistent, viscid,  greenish-white,  or  yellowish  coagula ;  or  after  previous 
extensive  discharges  of  fibrine  it  may  be  attenuated,  watery,  exuding 


AFTER    PARTURITION.  241 

thiough  the  coats  of  the  vessels  and  the  adjoining  tissues,  and  presenting 
but  few  and  trifling,  gelatinous,  soft  coagula.  Again,  after  previous  puru- 
lent or  sanious  absorption,  it  is  of  a  dirty  brown-red  or  chocolate  color, 
viscid,  glutinous,  depositing  dirty  white,  opaque,  fibrinous  concretions, 
which  in  the  heart  form  numerous  ramifications,  or  presenting  dark-red 
coagula,  which  are  paler  at  the  surface,  and  fusible.  Lastly,  if  the  dis- 
ease has  run  a  rapid  course,  the  blood  is  much  reduced  in  quantity,  and 
even  without  defibrination  having  taken  place,  it  is  attenuated  and  dis- 
colored, and  transudes  all  the  tissues.  The  fibrine  is  sometimes  found 
deposited  on  the  valves  of  the  heart  in  the  shape  of  vegetations,  without 
the  demonstrable  occurrence  of  previous  pericarditis.  The  severe  jaun- 
dice aifecting  women  during  the  puerperal  state  is  always  dependent  upon 
pyremia,  and  never  upon  an  appreciable  derangement  of  the  liver. 

The  formation  of  bone  occasionally  noticed  on  the  external  and  internal 
table  of  the  skull  after  parturition  is,  as  we  have  already  observed,  in  no 
connection  whatever  with  the  puerperal  process. 

6.  Termination  and  consequence  of  the  puerperal  processes. — We  con- 
fine ourselves  at  present  to  an  account  of  those  terminations  and  conse- 
quences of  the  fundamental  puerperal  processes,  which  are  not  to  be 
inferred  from  the  previous  remarks. 

Puerperal  peritonitis  generally  terminates  in  the  same  manner  as  ordi- 
nary peritonitis  ;  we  notice  as  particularly  important  the  unfavorable  ter- 
minations in  suppuration — phthisis — :of  the  peritoneum  and  the  adjoining 
tissues  (ulcerative  perforations  of  the  diaphragm,  the  abdominal  parietes, 
the  intestines,  the  bladder,  the  vagina,  &c.),  and  in  peritoneal  tuberculosis. 
The  exudations  upon  the  internal  sexual  organs  may  become  converted 
into  cellular  tissue,  and  by  fixing  the  tubes  in  an  unfavorable  position, 
even  without  occlusion  of  the  firnbriated  extremity,  cause  sterility. 

The  exudative  processes  occurring  on  the  internal  surface  of  the  uterus, 
as  well  as  the  exudation  in  the  uterine  parenchyma  accompanying  the 
former  and  metrophlebitis,  not  unfrequently  degenerate  into  suppuration 
of  the  uterus,  and  the  consequent  purulent  and  sanious  abscesses,  extend- 
ing chiefly  from  the  point  of  insertion  of  the  placenta  in  various  direc- 
tions, may  discharge  themselves  into  the  peritoneal  cavity.  The  afiection 
generally  runs  its  course  as  acute  uterine  phthisis. 

A  very  remarkable  and  important  result  of  the  exudative  processes  on 
the  internal  surface  of  the  uterus  is  tabes  of  the  uterus,  which  is  mani- 
fested by  extreme  brittleness  and  friability  of  the  uterine  fibre.  The 
uterus  very  rarely  attains  such  a  degree  of  involution  as  to  resume  the 
size  of  the  unimpregnated  organ  ;  it  generally  remains  considerably  en- 
larged, of  the  size  of  a  duck's  egg  or  a  man's  fist ;  its  tissue  at  the  same 
time  is  porous,  of  a  pale  red,  and  at  some  parts  of  a  slate  color ;  the  in- 
sertion of  the  placenta  continues  visible,  by  the  relaxation  of  the  tissue 
and  the  irregularity  of  the  inner  surface,  or  the  mucous  membrane  is  at 
this  place  invested  by  a  yellow  or  yellowish-white  ashy  substance,  the 
remains  of  the  exudation,  and  generally  presents  a  retiform  appearance. 

Metrophlebitis,  by  the  suppuration  of  the  coats  of  the  veins,  gives  rise 
to  the  formation  of  abscesses  in  the  uterine  parenchyma,  which  not  un- 
frequently anastomose  at  various  points,  and  thus  form  branched  sinuses. 
The  disease  is  very  persistent  if  the  uterus  passes  into  a  state  of  maras- 

VOL.  II.  16 


242  ABNORMITIES    OF 

inus,  and  if  it  maintains  dirty  brown  hemorrhagic  and  fetid  exudations  on 
the  internal  surface  of  the  uterus. 


SECT.    III. — ABNORMITIES    OF   THE   FALLOPIAN   TUBES. 

§  1.  Defect. — The  tube  may  be  absent  on  either  side  if  there  is  a  cor- 
responding defect  of  one-half  of  the  uterus,  but  this  certainly  is  not  al- 
ways the  case,  inasmuch  as  it  is  not  only  often  present  when  there  is  not 
even  a  trace  of  a  uterine  rudiment,  but  as  it  may  exist  in  the  shape  of  a 
solitary  coiled  tubercle  even  when  the  ovary  is  wanting. 

In  many  cases  the  Fallopian  tube  may  be  imperfectly  developed,  its 
coat  thin,  its  parenchyma  impoverished,  and  its  passage  narrowed  ;  or 
the  uterus  being  normal,  it  may  merely  appear  as  an  excrescence  of  the 
former,  terminating  blindly  above  the  uterine  horn,  or  it  may  be  inserted 
either  at  its  normal  place,  or  elsewhere,  without  presenting  an  open 
channel. 

When  a  Fallopian  tube  is  absent,  the  peritoneum  occasionally  presents 
a  fringed  process,  in  imitation  of  the  morsus  diaboli. 

§  2.  Anomalies  of  Calibre. — These  consist  in  dilatation  or  contrac- 
tion of  the  Fallopian  tube  ;  in  the  latter  case  obliteration  may  result. 

The  former  is  very  commonly  the  consequence  of  a  catarrh  of  the  tube 
owing  to  retention  of  the  mucous  secretion  from  contraction,  obliteration 
or  obturation  of  the  orifices ;  it  may  degenerate  into  dropsy  of  the  tube, 
an  affection  of  which  we  shall  say  more  at  a  future  period. 

The  latter  consists — independent  of  the  natural  contraction  of  the  tube 
in  the  decline  of  life — chiefly  in  a  diminution  of  the  passages  by  tume- 
faction of  the  mucous  membrane,  or  in  obstruction  of  the  same  by  mucus. 
The  contraction  may  pass  into  complete  closure  or  obliteration  of  the 
tubes  ;  it  chiefly  affects  the  uterine  orifice  in  consequence  of  catarrh ;  the 
fimbriated  extremity  is  often  closed  up  by  cellular  formations,  or  organ- 
ized peritoneal  exudation  (atresia  tubse).  The  imperforate  condition  of 
the  Fallopian  tubes  is  of  importance  in  regard  to  sterility. 

§  3.  Anomalies  of  Position  and  Direction. — Under  this  head  we 
reckon  the  very  unusual  congenital  irregularities  in  the  entrance  of  the 
tube  into  the  uterus,  whether  communicating  with  the  cavity  of  the  latter, 
or  terminating  in  its  tissue  blindly. 

Among  the  acquired  abnormities  the  deflections  and  curvatures  of  the 
tubes  become  the  more  important,  the  more  the  unattached  end  of  the 
tube  is  turned  away  from  the  ovary  and  fixed  in  its  abnormal  position 
by  the  products  of  peritoneal  inflammation.  It  is  found  variously  agglu- 
tinated to  the  neighboring  tissues,  and  is  particularly  apt  to  become  re- 
verted upon  and  fixed  to  the  posterior  surface  of  the  broad  ligament,  the 
ovary,  and  the  uterus. 

In  consequence  of  chronic  catarrh,  or  tubercular  disease  of  its  mucous 
membrane,  accompanied  by  hypertrophy  or  thickening  of  its  parietes, 
the  Fallopian  tube  is  apt  to  assume  a  serpentine  tortuous  course.  Or  if 
the  ovary  enlarges,  it  may  be  extended  to  an  unusual  length,  and  its 


THE    FALLOPIAN    TUBES.  243 

coats  thinned ;  and  if  it  happens  to  wind  round  the  former,  it  is  much 
stretched. 

The  tube  has,  like  the  ovary,  occasionally  been  found  in  the  abdominal 
ring,  within  an  inguinal  hernia. 

§  4.  Diseases  of  the  Tissues. 

1.  Hypercemia,  hemorrhage. — Hyperaemia  of  the  Fallopian  tube  is 
almost  always  a  symptom  of  general  congestion  of  the  sexual  organs,  and 
especially  of  the  uterus.     In  rare  cases,  however,  the  hyperaemia  of  the 
tube  predominates,  and  may  lead  to  hemorrhage  of  the  tube,  in  which 
case  a  larger  or  smaller  quantity  of  blood  is  effused  into  the  cavity  of 
the  peritoneum. 

We  have  twice  had  occasion  to  observe  the  occurrence  of  such  hemor- 
rhage in  the  course  of  abdominal  typhus ;  the  left  tube  was  distended,  its 
mucous  membrane  of  a  purple  tint,  and  congested.  We  have  once  seen 
it  in  the  body  of  a  female  who  was  attacked,  three  days  previous  to  her 
confinement,  with  pleuritis  and  hepatitis,  and  in  the  fourth  instance  it 
was  associated  with  retroversion  of  the  uterus.  Barlow  has  met  with  this 
condition  in  purpura,  in  consequence  of  or  connected  with  abortion  ;  and 
Brodie  has  observed  it  in  a  case  of  retention  of  menses  in  the  uterus,  owing 
to  occlusion. 

2.  Inflammation,     a.  Catarrhal  inflammation. — Chronic  catarrh,  or 
blennorrhoea  of  the  Fallopian  tube,  is  a  very  common  disease ;  it  is  fre- 
quently a  residue  of  a  puerperal  affection  of  the  mucous  membrane  of  the 
tube  ;  or  the  catarrh  may  have  extended  from  the  vagina  and  uterus  to 
this  point,  and  is  coexistent  with  vaginal  and  uterine  catarrh,  or  persists 
after  the  cessation  of  the  latter. 

At  the  same  time  the  tube  is  variously  dilated,  its  course  tortuous,  its 
coats  thickened  ;  the  mucous  membrane  is  tumefied,  purple,  slate-colored 
or  of  a  blackish-blue  tint ;  the  passage  contains  a  viscid,  transparent, 
milky  white  or  creamy,  or  a  bluish-gray,  or  yellow,  purulent  mucus. 

Catarrh  of  the  Fallopian  tube,  by  spreading  to  the  fimbriated  extremity 
gives  rise  to  peritoneal  inflammation  in  the  vicinity  of  the  orifice,  and 
thus  the  free  termination  may  become  adherent  to  the  neighboring  tissues 
and  be  closed  up,  whilst  the  uterine  orifice  is  obstructed  and  occluded  by 
the  catarrhal  tumefaction  of  the  mucous  membrane.  Catarrhal  inflam- 
mation in  this  manner  induces  sterility. 

The  chief  seat  of  catarrh  is  the  external  distended  portion  of  the  chan- 
nel, and  it  is  here  that  we  find  the  greatest  accumulation  of  blennor- 
rhoic  secretion. 

Under  the  above-mentioned  condition,  viz.  occlusion  of  the  orifices, 
catarrh  of  the  tube  is  very  often  converted  into  dropsy  of  the  tube,  a 
condition  similar  to  that  which  we  have  already  become  acquainted  with 
in  various  other  mucous  channels  and  cavities.  In  consequence  of  the 
accumulation  of  secretion  from  obstruction  of  the  orifices,  the  tube,  espe- 
cially towards  its  fimbriated  extremity,  becomes  so  much  distended,  that 
that  which  before  represented  a  tortuous  or  bent  channel,  is  now  con- 
verted into  a  simple  sac.  At  other  times,  several  saccular  dilatations 
form  between  the  separate  angles  and  the  projecting  duplicatures  of  the 
tubal  parietes,  and  give  rise  to  an  imperfectly  loculated  pouch,  which, 


244  ABNORMITIES    OF 

as  in  the  former  case,  may  contain  blennorrhoic  mucus,  a  puriform  se- 
cretion, a  true  purulent  inflammatory  product,  or,  if  the  mucous  mem- 
brane has  become  altered,  fluids  of  another  description.  It  is  to  be  ob- 
served, that  as  the  dilatation  proceeds,  the  texture  of  the  mucous  mem- 
brane  is  changed,  and  the  latter  is  converted  into  a  serous  membrane  ; 
its  secretion  may  be  a  thin,  watery,  serous,  or  albuminous  synovoid, 
colorless  liquid,  giving  the  tube  the  appearance  of  a  transparent  sero- 
fibrous  bladder ;  or  it  may  be  variously  colored,  yellowish,  brown,  black- 
ish-green, chocolate-colored,  inky,  and  more  thick  and  flocculent,  con- 
sisting in  part  of  inflammatory  products  on  the  internal  surface  of  the 
membrane. 

The  hydropic  Fallopian  tube  not  unfrequently  attains  the  size  of  a 
duck's  or  goose's  egg,  or  even  of  a  man's  fist ;  although  not  a  usual  oc- 
currence, still  it  is  satisfactorily  proved  that  the  contents  are  sometimes 
discharged  into  the  uterus,  and  thus  carried  off. 

In  extremely  rare  instances  chronic  catarrh  of  the  Fallopian  tube  be- 
comes acute,  and  passes  into  suppuration ;  its  contents  may  then  be 
either  poured  into  a  cavity  of  the  peritoneum,  which  has  been  circum- 
scribed by  adhesive  inflammation,  or  into  the  perforated  intestine,  which 
has  been  previously  agglutinated  to  the  tube. 

b.  JExudative  processes. — An  exudative  process  scarcely  occurs  on  the 
mucous  membrane  of  the  Fallopian  tube,  except  in  combination  with  a 
similar  condition  of  the  internal  uterine  surface  after  childbirth.  The 
tubes  are  tumefied  and  infiltrated ;  their  mucous  membrane  is  variously 
reddened,  discolored,  excoriated,  softened,  and  everted  at  the  fimbriated 
extremity  ;  the  passage  of  the  tube  is  dilated,  especially  at  its  outer  end, 
and  filled  with  various  products,  purulent  and  sanious  fluids,  and  in  uterine 
croup  with  coagulable  lymph,  assuming  the  shape  of  a  tubular  concre- 
tion. The  exudative  process  has  extended  from  the  uterus  to  the  tube. 

3.  Adventitious  growths,  a.  Cysts. — Serous  cysts  are  very  often 
formed  at  the  fimbriated  extremity  of  the  tubes,  and  in  its  vicinity ; 
and  they  are  generally  attached  by  a  pedicle,  which  sometimes  attains  a 
considerable  length.  They  scarcely  ever  become  larger  than  a  bean  or 
hazel-nut. 

b.  Fibroid  tumors. — These  are  not  frequent;  they  are  rarely  larger 
than  a  pea,  and  occupy  the  parenchyma  of  the  tube  in  the  shape  of  round 
or  discoid  tumors. 

c.  Tubercle. — Tubercle  of  the  Fallopian  tubes  (Fallopian  mucous  mem- 
brane) is  generally  associated  with  uterine  tubercle  ;  but  it  is  remarkable 
that  it  sometimes  occurs  independently  of  the  latter,  or  in  a  condition  of 
higher  development.     It  therefore  follows  that  in  many  cases  of  tuber- 
cular affection  of  the  internal  sexual  organs,  the  mucous  membrane  of 
the  Fallopian  tube  is  the  primary  seat  of  disease. 

Tubercle  of  the  tube  is  almost  always  presented  to  us  in  the  dead  sub- 
ject, in  the  shape  of  tubercular  infiltration  and  complete  disorganization 
of  the  mucous  membrane  ;  the  latter  being  converted  into  a  softened 
purulent  layer  of  yellowish-white,  cheesy,  lardaceous  matter,  which  is 
cracked  and  friable,  and  chokes  up  the  passage.  The  tube  is  more  or 
less  swollen,  its  course  tortuous,  it  is  hard  to  the  touch,  and  its  parenchy- 
matous  coat  thickened,  and  converted  into  a  dense  lardaceous  tissue. 


THE    OVARIES.  245 

The  fimbriated  extremity  presents  a  very  peculiar  appearance ;  the  mu- 
cous membrane,  which  is  infiltrated  with  tubercular  matter,  being  pushed 
out  in.  the  shape  of  a  cauliflower  excrescence,  and  everted  upon  the  peri- 
toneum. 

Opportunities  are  very  rarely  afforded  of  observing  the  disease  at 
its  commencement,  which  occurs  in  the  shape  of  a  deposit  of  crude,  gray, 
discrete,  or  agglomerated  tubercular  granulations.  In  the  above-de- 
scribed shape,  it  must  doubtless  be  viewed  as  the  result  of  a  tumultuous 
localization  of  the  general  disease,  occurring  under  symptoms  of  con- 
gestive inflammation.  The  remarks  made  in  reference  to  uterine  tubercle 
apply  to  this  affection. 

d.  Carcinoma. — Except  when  involved  in  cancer  of  the  peritoneum, 
the  tube  is  not  affected  by  this  disease ;  and  even  an  extension  from 
the  uterus  or  other  adjoining  tissues  by  mere  contiguity,  after  pseudo- 
membranous  attachments  have  been  effected,  is  very  rare.  Still  I  have 
noticed  one  case  of  ovarian  cancer,  in  which  the  tubes,  without  being 
agglutinated  to  the  former,  were  thoroughly  diseased  ;  the  parietes  were 
very  much  thickened,  callous,  contracted  in  their  long  diameter,  and 
curled  up. 

SECT.   IV. — ABNORMITIES   OF   THE   OVARIES. 

§  1.  Defect  of  Formation. — It  is  very  unusual  for  one  of  the  ovaries 
to  be  wanting,  if  the  sexual  apparatus  is  otherwise  normal. 

The  ovaries  often  appear,  together  with  the  other  portions  of  the  sexual 
organs,  in  a  state  of  imperfect  development,  and  small ;  and,  on  account 
of  the  depth  at  which  the  Graafian  follicles  are  placed,  of  uniform  den- 
sity and  hardness,  and  with  an  even  and  smooth  surface. 

§  2.  Deviations  of  Size. — We  find  various  enlargements  occurring  in 
the  ovaries,  which  form  a  contrast  with  the  just-mentioned  smallness  of 
the  ovaries  and  their  diminution  at  the  decline  of  life ;  the  latter  affec- 
tion only  comes  within  the  domains  of  pathology  if  it  occurs  prematurely. 
We  shall  have  occasion  to  notice  them  all  under  the  head  of  textural  dis- 
ease, and  therefore  do  not  here  enter  into  a  more  minute  examination  of 
the  subject.  We  here  merely  allude  to  that  form  of  ovarian  dropsy 
which  results  from  the  excessive  development  or  hypertrophy  of  one  or 
more  Graafian  vesicles,  as  a  subject  coming  under  the  above  denomina- 
tion ;  but  it  will  be  more  practical  to  consider  it  fully  when  we  speak  of 
the  formation  of  ovarian  cysts. 

§  3.  Diseases  of  the  Tissues. — These  diseases  affect  either  the  cellule- 
fibrous  substance  (stroma)  and  the  fibrous  capsule  of  the  ovary,  or  the 
follicles,  or  both  together,  as  we  shall  have  occasion  to  explain  in  the 
subsequent  sections  that  relate  more  particularly  to  this  point.  We  con- 
fine ourselves  to  the  most  important  and  conspicuous  affections  of  the 
follicles  and  their  contents. 

1.  HypercemtOj  Apoplexy. — Hypersemia  of  the  ovary,  affecting  both 
its  stroma  and  the  external  layer  of  the  follicle,  occurs  physiologically 
in  menstruation ;  but  it  also  accompanies  numerous  pathological  pro- 


246  ABNORMITIES    OF 

cesses  in  the  sexual  apparatus,  and  is  sometimes  permanent.  Its  cha- 
racters are  tumefaction  of  the  ovary,  softening  of  its  tissue,  vascu- 
larity,  and  darker  color ;  permanent  hypersemia  gives  rise  to  a  gradual 
increase  of  size,  to  hypertrophy  of  the  stroma,  and  enlargement  of  the 
povary. 

Hypersemia  affecting  the  more  developed  follicles  that  are  seated  at 
the  surface  of  the  ovary  often  induces  effusion  of  blood  into  the  cavity 
of  the  follicle  or  apoplexy.  One  or  more  cysts,  varying  in  size  from  a 
pea  to  a  hazel-nut,  are  found  in  the  ovary ;  they  project  more  or  less 
above  its  surface,  after  having  perforated  the  fibrous  sheath  of  the  ovary, 
and  are  at  once  recognized  by  their  ^contents  being  visible  through  the 
parietes  of  the  follicle.  If  seen  shortly  after  the  occurrence  of  extrava- 
sation, they  are  tense :  but  more  commonly  a  certain  amount  of  coagu- 
lation has  been  effected  in  their  contents,  and  they  then  appear  slightly 
collapsed,  and  present  fluctuation.  They  now  contain  a  dark-red 
loose  coagulum,  which  is  invested  by  a  white  or  colored  fibrinous  coa- 
gulum varying  in  thickness.  In  the  course  of  time  the  coagulum 
assumes  a  rusty  or  yellow  color,  is  converted  into  a  pulp  which 
gradually  becomes  inspissated,  and  yields  the  above-mentioned  fibrinous 
coagulum  and  serosity,  the  latter  being  in  its  turn  removed  by  exosmose 
and  absorption.  The  entire  cyst  contracts,  retaining  traces  of  the  origi- 
nal lining  coagulum  of  fibrine  and  of  its  yellow  deposit,  and,  perhaps, 
also,  a  yellow,  indurated,  friable,  chalky  residue  of  the  coagulated  blood ; 
it  may  become  reduced  to  less  than  the  normal  size  of  the  follicle,  and 
from  drawing  in  the  fibrous  sheath  of  the  ovary,  cause  the  appearance  of 
a  cicatrix.  The  contents  and  parietes  of  the  apoplectic  cyst  consequently 
present  an  appearance  which  varies  according  to  the  length  of  time  that 
has  elapsed.  We  very  often  find  cysts  of  different  dates  in  one  or  both 
ovaries. 

It  is  evident  that  this  effusion  of  blood  must  induce  a  destruction  of 
the  germ,  and,  at  last,  cause  an  entire  obliteration  of  the  follicle.  The 
cicatrix  naturally  always  presents  a  greater  or  less  resemblance  to  the 
corpus  luteum.  Although  the  amount  of  effusion  is  often  very  consider- 
able, rupture  of  the  follicle  and  hemorrhage  into  the  peritoneal  cavity 
is  of  very  rare  occurrence. 

The  most  common  cause  of  this  affection  is  excessive  menstrual  con- 
gestion, and  it  undoubtedly  comes  within  the  sphere  of  pathological  in- 
quiry (vide  Negrier). 

2.  Inflammation. — Inflammation  occurring  in  the  ovary,  independently 
of  the  puerperal  state,  is  limited  to  the  follicles.  The  coats  of  a  follicle 
are  occasionally  found  injected,  reddened  and  softened,  and  friable ;  the 
contents  are  opaque,  flocculent,  reddened  by  an  admixture  of  blood,  and 
not  unfrequently  purulent.  Each  of  these  processes,  even  in  its  slightest 
form,  is  followed  by  a  destruction  of  the  germ  by  means  of  the  exuda- 
tion ;  obliteration  of  the  follicle  soon  ensues,  and  the  first  impulse  is  thus 
given  to  its  conversion  into  a  common  serous  cyst,  which  in  its  turn  may 
grow  into  ovarian  dropsy. 

On  the  other  hand,  inflammation  resulting  from  childbirth,  puerperal 
inflammation,  involves  the  entire  ovary,  though  probably  in  the  first 
instance  the  stroma  only ;  it  is  this  that  generally  gives  rise  to  the  sup- 
puration and  abscess  of  the  ovary  noticed  by  ancient  and  modern  ob- 


THE    OVARIES.  247 

servers.  It  not  only  varies  much  in  intensity,  but,  like  the  other  puer- 
peral processes,  in  kind  also  ;  this  is  particularly  evidenced  by  the 
product  and  the  state  of  the  tissues.  According  to  the  manner  in 
which  it  is  complicated  with  other  puerperal  affections,  it  plays  the 
chief,  or  only  a  secondary  part,  as  will  become  apparent  from  the  follow- 
ing remarks. 

The  ovary  may  be  swollen  to  the  size  of  a  hen's,  duck's,  or  goose's  egg, 
presenting  various  discolorations,  and  being  at  the  same  time  collapsed 
and  pulpy,  its  tissue  distended  by  a  dirty  yellowish-brown,  brownish- 
green,  chocolate-colored  fluid,  or  converted  into  a  fetid  pulp  ;  this  is 
putrescence  of  the  ovary. 

Or  the  ovary  may  present  a  pale  greenish,  or  yellowish,  or  reddish 
gelatinous  viscid  product,  which  is  deposited  in  the  stroma  in  large  quan- 
tities ;  the  latter  being  at  the  same  time  friable  or  semi-fluid,  the  fol- 
licles tumid,  their  coats  swollen,  and  their  contents  opaque  and  floccu- 
lent.  The  ovary  is  at  the  same  time  enlarged  and  tense,  as  in  the  former 
case. 

Again,  the  deposit  may  be  serous  (of  a  pale  yellow  or  reddish  color) 
or  fibrinous  (of  a  yellowish-white  color),  and  fusible  ;  filling  the  tissues, 
and  causing  the  follicles  to  present  an  opaque  appearance.  The  tissue 
of  the  ovary  and  the  coats  of  the  follicles  are  congested  and  more  or  less 
reddened,  and  both  are  softened  and  friable. 

Again,  the  congested  stroma  of  a  moderately  tumefied  ovary  may  be 
infiltrated  with  a  flocculent  serosity,  which  is  rendered  opaque  by  plastic 
exudation. 

In  all  these  cases  the  parenchyma  of  the  ovary  is  more  or  less  ecchy- 
mosed  ;  its  sheath  presents  exudations  of  various  kinds,  under  which  dif- 
ferently-colored, spotted,  or  striated  suffusions  are  found ;  the  tissue  at 
the  same  time  being  softened,  and  extremely  friable. 

These  are  the  chief  varieties  and  degrees  of  puerperal  inflammation  of 
the  ovaries ;  they  enter  into  complications  with  other  puerperal  processes, 
and  especially  with  endometritis  and  peritonitis,  and  give  rise  to  the 
same  products  ;  they  differ,  however,  in  intensity,  and  the  inflammation 
of  the  ovary  may  either  be  the  predominating  disease,  or,  as  is  com- 
monly the  case,  the  subordinate  or  partial  symptom  of  an  extensive  exu- 
dative process  of  the  uterine  or  tubal  mucous  membrane,  of  the  tissue 
of  the  uterus,  or  the  adjoining  accumulations  of  cellular  tissue  or  of  the 
peritoneum. 

We  have,  lastly,  to  allude  to  the  condition  presented  by  the  ovaries  in 
puerperal  exudative  disease,  when  they  are  not  themselves  involved  in 
the  latter  process ;  like  the  other  tissues  in  the  vicinity  of  the  seat  of 
disease,  they  are  infiltrated  with  serum,  softene^flabby,  pale,  and  friable. 

Exudative  processes  either  affect  one,  or,  more  frequently,  both  ovaries 
at  the  same  time,  though  generally  not  in  the  same  degree.  They  may 
run  a  very  rapid  course,  sometimes  even  assuming  such  violence  as  to  in- 
duce a  spontaneous  rupture  of  the  ovary  ;  they  prove  fatal  by  the  inten- 
sity of  the  general  disease ;  or  by  the  exudative  processes  with  which 
they  are  complicated  ;  or  they  may  terminate,  after  a  slower  progress, 
in  suppuration  (phthisis)  of  the  ovary.  In  the  case  of  recovery,  sterility 
is  entailed  upon  the  affected  ovary,  in  consequence  of  destruction  of  the 
germs  and  obliteration  of  the  follicles. 


248  ABNORMITIES    OF 

Suppuration  either  commences  at  separate  points  which  gradually 
coalesce,  or  it  is  set  up  equally  throughout.  The  parenchyma  of  the 
ovary  is  by  degrees  consumed,  and  the  organ  converted  into  a  purulent 
cyst,  which  sometimes  attains  a  very  considerable  size. 

The  abscess  itself  is  sometimes  borne  for  a  long  time  without  marked 
symptoms,  and  nature  does  her  utmost  to  prevent  a  free  discharge  of  it 
into  the  peritoneal  cavity ;  for  adhesions  are  formed  between  the  ovary 
and  the  adjoining  viscera,  either  in  consequence  of  peritonitis  having 
been  combined  with  the  inflammation  of  the  ovary,  or  from  circum- 
scribed inflammations  of  the  peritoneum  having  been  set  up  in  the  course 
of  the  ovarian  disease.  Thus  the  ovary  may  become  agglutinated  to  the 
broad  ligaments,  to  the  pelvic  parietes,  the  uterus,  the  bladder,  or  the 
rectum  and  the  sigmoid  flexure,  to  the  caecum  and  the  vermiform  process 
and  the  small  intestine  ;  and  it  is  generally  attached  to  several  of  these 
viscera  at  the  same  time.  When  at  last  the  suppurative  process  has 
eaten  away  the  fibro-serous  investment  of  the  ovary,  and  caused  its 
rupture,  the  discharge  follows,  from  a  yielding  of  the  adhesions,  into  a 
circumscribed  cavity  ;  newpartial  inflammatory  attacks  of  the  peritoneum 
ensue,  or  the  pus  meets  with  an  organ  which  presents  firm  attachments. 
In  the  former  case,  the  circumscribed  processes  not  unfrequently  pass 
into  universal  peritonitis,  or  this  is  induced  by  an  extravasation  of  the 
pus  through  the  relaxed  adhesions.  Again,  in  either  of  these  cases,  the 
suppuration  may  extend  to  the  adjoining  viscera,  and  the  contents  of 
the  abscess  be  discharged  outwards,  indirectly  through  a  circumscribed 
peritoneal  sac,  or  directly  in  the  hypogastric  or  umbilical  regions  ;  or 
into  a  portion  of  the  intestine,  into  the  bladder  or  vagina.  Suppuration 
occasionally  takes  place  in  the  pelvic  cellular  tissue  investing  the  iliac 
muscle ;  such  abscesses  pass  through  the  femoral  ring  or  through  the 
ischiatic  notch,  and  accordingly  make  their  appearance  on  the  thigh  or 
the  nates.  They  may  thus  discharge  themselves  at  a  considerable  dis- 
tance from  the  original  nidus. 

3.  Morbid  groivths.  a.  Cysts. — In  no  part  of  the  body  are  cysts  so 
frequent,  or  so  various  as  in  the  ovary,  in  the  peritoneum,  in  the  neigh- 
borhood of  the  internal  sexual  organs,  or  in  the  subperitoneal  cellular 
tissue  ;  as,  for  instance,  between  the  laminae  of  the  broad  ligaments,  and 
at  the  fimbriated  extremities  of  the  tubes.  Moreover,  the  size  attained 
by  the  ovarian  cysts  is  extraordinary.  It  is  more  practical  to  consider- 
all  the  different  cysts  at  this  place,  though  we  shall  parenthetically  indi- 
cate the  position  they  occupy  in  morbid  anatomy,  and  have  to  revert  to 
them  in  the  sequel.  At  the  bedside  the  term  ovarian  dropsy  is  equally 
applied  to  all  cysts,  provided  they  fluctuate.  We  commence  with  the 
simple  formations,  and  piss  on  to  those  which,  in  reference  to  original 
development,  structure,  growth,  pathological  importance,  and  contents, 
are  more  complicated. 

«.  Simple  cysts. — They  are  of  very  common  occurrence.  There  are 
either  one  or  several  unilocular  cysts  in  the  ovary ;  at  times  they  are 
even  so  numerous,  that  the  ovary  appears  converted  into  an  aggregation 
of  cysts.  They  are  placed  near  one  another,  each  one  being  formed 
from  the  stroma,  independently  of  the  other,  and  they  have  a  rounded  form. 
If  they  enlarge,  they  come  into  mutual  contact,  their  parietes  adhere  to 


THE    OVARIES.  249 

one  another,  and  they  are  flattened  by  reciprocal  pressure ;  the  impres- 
sion may  thus  arise  that  several  have,  in  the  manner  of  the  compound 
cysts,  been  formed  within  the  parietes  of  the  same  matrix.  They  attain  a 
considerable  size,  rarely,  however,  exceeding  that  of  a  man's  head.  In 
this  case  the  solitary  cyst,  or  one  of  several  cysts,  undergoes  extreme 
development,  whilst  the  remainder  continue  undeveloped.  They  gene- 
rally have  delicate  sere-fibrous  parietes,  and  may  contain  a  colorless,  or 
pale  yellowish  or  greenish,  serous,  or  a  more  consistent  yellow,  brownish, 
colloid  substance,  or  an  opaque  chocolate-colored  or  inky  fluid.  In 
many  cases  they  are  undoubtedly  formed  from  the  Graafian  follicles ;  and 
it  appears  that  an  inflammatory  process  is  particularly  liable  to  give  the 
first  impulse  to  this  metamorphosis.  They  are  probably,  however,  as 
often  new  formations  from  the  beginning  ;  and  this  is  the  more  likely  in 
those  cases  in  which  their  number  exceeds  the  average  number  of  Graa- 
fian follicles.  Allied  to  them  are  the  adipose  cysts  of  the  ovaries ; 
these  we  shall,  however,  discuss  at  a  later  period,  on  account  of  their 
numerous  peculiarities. 

ft.  Compound  cysts. — They  occur  in  the  two  forms  described  by 
Hodgkin.  In  the  one,  new  cysts  are  formed  in  the  coats  of  an  older 
cyst,  and  although  projecting  into  the  cavity  of  the  latter,  they  do  not 
actually  grow  into  it ;  the  oftener  this  process  is  repeated,  the  more 
complicated  the  morbid  product  becomes.  In  the  other,  an  endogenous 
generation  of  cysts  is  effected,  cysts  being  formed  upon  the  internal  sur- 
face of  another  "cyst,  and  being  either  sessile  or  pediculated  ;  the  matrix 
is  sometimes  entirely  filled,  the  cysts  discharge  themselves  into  it  and 
become  adherent  to  it,  and  subsequently  a  third  order  of  cysts  may  be 
formed  within  them.  &c.  The  two  forms  are  often  seen  in  the  same 
adventitious  growth. 

These  cysts  are  capable  of  very  extensive  development ;  to  them  and 
to  the  following  variety  the  large  encysted  ovarian  dropsies  are  due. 
The  separate  cells  or  loculi  contain  the  above-mentioned  different  sub- 
stances, and  their  parietes,  especially  those  of  older  cysts,  are  generally 
of  considerable  thickness,  and  of  dense  texture.  They,  too,  may  proba- 
bly in  the  first  instance  be  developed  from  a  Graafian  vesicle  as  simple 
cvsts,  or  they  may  form  as  adventitious  growths  ;  the  remaining  substance 
of  the  ovary  is  spread  out  at  the  base  of  the  cyst ;  it  is,  as  it  were,  thrown 
open,  and  its  tissue  condensed. 

?.  A  third  form,  which  very  much  resembles,  and  is  closely  allied  to, 
the  last,  is  of  a  cancerous  nature,  and  belongs  to  the  areolar  variety  of 
carcinoma.  In  the  shape  which  we  are  about  to  describe,  it  rarely  occurs 
anywhere  but  in  the  ovary.  It  is  an  accumulatum  of  numerous  fibrous 
sacs,  which  contain  various  substances,  but  for  the  most  part  a  glutinous, 
viscid  matter.  They  diminish  in  size  from  the  circumference  towards 
the  interior,  and  especially  towards  the  base  of  the  morbid  growth ;  so 
that  the  latter  represents  a  condensed  alveolar  mass,  the  alveoli  or  folli- 
cles of  which  consist  of  a  white,  shining,  fibrous  tissue,  and  contain  a 
colorless  or  grayish,  yellowish,  yellowish-green,  or  reddish  viscid  gelatine. 
We  have  here  an  areolar  cancer,  the  peripheral  follicles  of  which  are 
converted  into  large  sacs.  This  species  of  ovarian  dropsy,  which,  for 
the  sake  of  distinction  from  the  other  varieties,  we  term  alveolar  dropsy, 


250  ABNORMITIES    OF 

is  proved  to  be  malignant,  not  only  by  its  being  accompanied  by  well- 
marked  cachexia,  but  also  by  its  complication  with  cancer  (especially  of 
the  medullary  variety)  in  the  same  organ,  and  with  other  varieties  of 
cancer  in  other  organs,  as  the  peritoneum,  or  the  stomach,  and  moreover 
by  its  complication  with  mollities  ossium. 

As  already  remarked,  it  attains  an  enormous  size,  and  like  the  com- 
posite cysts,  occasionally  exists  in  both  ovaries  at  the  same  time.  In 
the  composite  as  in  the  alveolar  cyst,  one  peripheral  follicle  is  subject 
to  preponderating  growth,  and  establishes  ovarian  dropsy. 

To  the  above  special  observations  we  add  the  following  remarks  as 
important  for  the  diagnosis.  Generally  but  one  ovary  is  affected,  though 
the  two  are  often  attacked  successively,  so  that  the  increase  of  size  is 
much  more  considerable  in  one  than  in  the  other. 

The  enlarged  ovary  remains  within  the  pelvis  as  long  as  it  does  not 
exceed  certain  dimensions ;  it  either  continues  freely  movable  between 
the  uterus  and  its  lateral  appendages  and  the  rectum,  or  becomes  fixed, 
and,  as  it  were,  wedged  in  by  the  formation  of  false  membrane.  If  it 
increases  still  further,  and  is  adherent  to  the  pelvis,  it  grows  into  the 
abdominal  cavity ;  otherwise  it  leaves  its  previous  position,  and  rises  into 
the  abdomen,  where  it  continues  movable,  until,  in  consequence  of  peri- 
toneal inflammation,  it  has  formed  adhesions  with  adjoining  viscera,  or 
becomes  fixed  by  entirely  filling  out  the  cavity.  In  the  course  of  this 
change  of  position,  it  drags  the  uterus  after  it  by  means  of  its  ligament, 
so  that  this  organ,  together  with  the  vagina,  is  not  only  elongated,  but 
obtains  a  slanting  form,  which  is  recognizable  by  the  oblique  and  elevated 
position  of  the  os  tincse.  (Page  214  and  215.) 

If  both  ovaries  are  involved  in  the  disease,  inasmuch  as  they  are 
generally  aifected  successively,  and  one  is  less  enlarged  than  the  other, 
the  smaller  one  remains  in  the  pelvis,  and  its  retention  is  proportionate 
to  the  obstacles  offered  to  its  ascent  by  its  fellow.  It  is  wedged  in  be- 
tween the  uterus  and  the  rectum,  even  if  there  are  no  adhesions.  If 
we  find  the  above-mentioned  irregularity  in  the  uterus  and  the  vagina,  and 
at  the  same  time  discover  an  immovable  tumor  in  the  pelvis,  which 
weighs  upon  the  posterior  walls  of  the  vagina,  and  pushes  it,  together 
with  the  uterus,  forwards,  it  may  be  assumed,  if  there  are  no  contraindi- 
cations, that  both  ovaries  are  diseased. 

The  cysts  very  frequently  become  the  seat  of  inflammation.  This 
either  attacks  at  different  periods  the  peritoneum,  investing  the  diseased 
ovary,  and  causes  its  adhesions  and  fixation  in  the  abdominal  cavity,  or 
the  fibre-serous  parietes  of  the  cysts  themselves  inflame,  and  the  result- 
ing products  are  deposited  upon  their  internal  surface  or  in  their  cavity. 
Thus  we  find  not  only  all  the  exudations  with  their  metamorphoses,  that 
occur  on  the  normal  serous  membranes,  at  this  place,  but  also  all  the  fur- 
ther effects  of  this  variety  of  inflammation.  Our  observations,  however, 
lead  us  to  except  the  tubercular  metamorphosis  of  the  inflammatory  .pro- 
duct ;  we,  at  least,  have  never  met  with  it,  in  spite  of  very  extensive  and 
various  opportunities. 

As  the  dropsical  ovary  enlarges,  it  occupies  more  and  more  of  the 
abdominal  cavity ;  it  distends  the  belly  to  an  enormous  extent,  pushes 
the  intestine  into  the  inguinal  regions,  forces  the  epigastric  viscera,  to- 


THE    OVARIES.  251 

getlier  with  the  diaphragm,  into  the  thorax,  and  causes  universal  emacia- 
tion, proportionate  to  the  increase  of  the  tumor.  The  adventitious  growth 
enters  into  combination  with  fibroid  and  carcinomatous  products,  and 
especially  with  medullary  cancer,  in  the  manner  which  we  shall  have  oc- 
casion to  explain  further  on.  It  is  the  less  frequently  complicated  with 
tubercle,  the  more  it  approaches  the  character  of  areolar  cancer,  and  the 
more  it  compresses  the  thorax  by  its  increase  of  size. 

There  are  a  few  cases  on  record  in  which  the  dropsical  ovary  is  said  to 
have  discharged  its  contents  into  the  Fallopian  tube,  and  thus  into  the 
uterus,  and  externally. 

d.  The  simple  cyst,  or  the  cyst  with  secondary  endogenous  formations, 
also  occurs  in  the  shape  of  cystosarcoma  of  the  ovary ;  this,  however,  is 
much  rarer  than  any  of  the  above-mentioned  three  varieties,  and  scarcely 
ever  attains  the  extreme  size  to  which  these  are  developed. 

£.  Finally,  we  observe  that  cysts  with  anomalous  contents,  viz.  en- 
cysted fatty  tumors,  occur  nowhere  so  frequently  as  in  the  ovary  ;  either, 
and  most  commonly,  as  a  simple  cyst,  or  as  the  composite  cyst,  in  which 
one  of  the  cysts  of  the  secondary  formation  is  distinguished  from  the  rest 
by  its  adipose  contents,  or,  though  rarely,  in  the  shape  of  a  compound  adi- 
pose cyst.  We  often  find  the  fat  associated  with  a  formation  of  hair,  fre- 
quently, too,  of  teeth,  and  sometimes  with  the  formation  of  bone.  Like  the 
serous  cysts,  the  adipose  cysts  are  undoubtedly  often  formed  from  a  Graa- 
fian  vesicle  ;  they  occur  most  frequently  in  the  prime  of  life,  rarely  at  the 
period  of  puberty,  and  still  less  frequently  in  childhood.  We  have,  how- 
ever, one  case  of  adipose  cyst  of  the  ovary  in  the  museum  of  Vienna, 
belonging  to  a  child  of  six  years.  They  grow  very  slowly,  and  rarely 
exceed  the  size  of  a  child's  head.  There  generally  is  but  one  adipose  cyst 
in  one  of  the  ovaries ;  the  two  are  rarely  affected  at  the  same  time. 

The  inflammation  to  which  this  variety  is  equally  subject  with  the 
other  cysts,  gives  rise  to  a  dilatation  of  the  cyst,  as^well  as  to  an  essential 
alteration  in  its  contents  by  means  of  the  exudation.  It  occasionally  ter- 
minates in  suppuration,  and  discharge  of  the  contents  externally  at  the 
navel,  in  the  hypogastric,  or  inguinal  regions ;  the  contents  consist  chiefly 
of  pus  mixed  up  with  hairs.  Under  certain  circumstances,  which  will  be 
explained  in  the  sequel,  the  partially  liquefied  contents  of  an  adipose 
cyst  assume  a  peculiar  form.  In  a  female,  46  years  of  age,  who  died  of 
internal  hernia,  the  right  ovary  was  found  converted  into  an  ellipsoid 
fibrous  sac  of  the  size  of  a  man's  head,  and  nine  inches  in  its  long  diame- 
ter ;  it  had  mounted  above  the  pelvis,  and  lay  obliquely  in  the  left  iliac 
fossa.  Its  inferior  apex  was  attached  to  the  ovarian  ligament ;  the  other, 
which  was  directed  upwards  and  outwards,  was  attached  to  the  anterior 
surface  of  the  middle  portion  of  the  jejunum,  by  means  of  a  cellular  band 
of  an  inch  in  breadth.  The  sac  had  been  twice  turned  upon  its  axis  ;  it 
contained  a  brown,  fatty,  gelatinous  fluid,  in  which,  besides  a  ball  of  the 
size  of  a  walnut,  composed  of  hairs  that  were  matted  together,  there 
floated  seventy-two  bodies  of  the  size  of  a  filbert,  and  a  much  larger 
number  of  smaller  bodies  of  the  size  of  a  pea,  consisting  of  a  greasy  fat. 
They  were  of  a  yellowish  color,  and  from  mutual  pressure  had  a  polyhe- 
dral surface,  and  presented  concentric  layers.  The  cyst  was  not  only 
surrounded  by  coils  of  the  small  intestine,  but  two  portions  of  intestine 


252  ABNORMITIES     OF 

also  passed  underneath  it.  It  may  therefore  be  said  to  have  represented 
a  capsule,  which  both  from  its  form  and  attachment,  and  from  the  cir- 
cumstances of  its  having  been  found  rotated  upon  its  axis,  resembled  a 
dredging-box  (granulirbuchse),  the  rotations  of  which  had  converted  the 
contained  fat  into  the  globular  bodies  above  described. 

b-  Anomalous  production  of  fibrous  and  osseous  tissue. 

a.  Fibrous  tissue  is  formed — 

In  the  shape  of  fibroid  exudation  on  the  internal  surface  of  the  simple 
cysts,  but  more  especially  on  that  of  the  composite  and  areolar  cysts. 

As  a  subperitoneal  (subserous)  new  growth  (so-called  cartilaginescence) 
in  the  cystic  parietes. 

As  a  fibroid  tumor  ;  this  rarely  attains  a  larger  size  than  that  of  a  hemp 
seed  or  pea.  We  must  except  those  cases  in  which  the  tumor  has  formed 
in  the  parietes  of  a  compound  cyst. 

As  a  dirty  white  or  yellow,  plicated,  curled,  soft  concretion,  within 
which,  not  unfrequently,  a  cavity  may  be  traced.  These  concretions  ap- 
pear to  be  Graafian  follicles  which,  after  having  undergone  inflammatory 
thickening,  shrivel  up  and  become  obliterated ;  after  puerperal  processes 
we  find  them  occasionally  in  the  shape  of  soft,  collapsed,  friable  sacculi, 
whilst  under  other  circumstances  they  appear  as  solid,  dense,  coriaceous 
cysts. 

As  a  cicatrix,  presenting  a  rounded,  nodulated  wheal,  with  a  yellow, 
rusty,  or  black  nucleus,  resulting  from  follicular  apoplexy  of  the  ovary. 

/3.  A  formation  of  bone  occurs — 

In  the  shape  of  so-called  ossification  (earthy  concretion)  in  the  majority 
of  the  just-mentioned  fibroid  growths,  and  more  particularly  in  the  fibroid 
exudation,  and  in  the  subserous  fibroid  formations  of  the  dropsical  ovary. 

As  genuine  bone,  in  various  forms  that  offer  but  a  weak  analogy  to  one 
another,  and  in  the  adipose  cysts. 

c.  Tubercle. — The  occurrence  of  tubercle  in  the  ovaries  is  at  least 
doubtful ;  so  far  as  our  own  investigations  and  observations  go,  we  must 
deny  it  altogether. 

d.  Carcinoma. — Cancer,  on  the  other  hand,  if  we  collect  all  that  comes 
under  this  denomination,  is  not  unusual. 

a.  The  most  frequent  form  is  areolar  cancer  in  the  above-described 
shape  of  areolar  hydrops  ovarii :  the  conversion  of  the  peripheral  follicles 
of  the  ovary  into  large  sacs,  is  a  peculiarity  which  but  rarely  presents 
itself  in  other  tissues.  We  have  already  alluded  to  all  the  important 
points  connected  with  this  subject. 

/?.  Medullary  carcinoma  is  less  frequent  than  the  former.  There  are 
two  varieties.  The  first  occurs  in  the  shape  of  rounded  adventitious 
growths,  varying  in  size  from  a  goose's  egg,  to  a  child's  head,  and  in- 
vested with  a  fibrous  sheath ;  it  sometimes  perforates  the  latter,  and  grows 
freely  into  the  peritoneal  cavity.  In  the  interior  we  occasionally  find 
large  masses  of  cellular  tissue  traversing  the  substance  of  the  tumors  in 
the  shape  of  septa,  and  inducing  considerable  density  of  the  mass ;  at 
other  times  the  entire  ovary  appears  infiltrated  with  soft  encephaloid 
matter,  so  as  to  present  fluctuation.  The  carcinomatous  matter  is  either 
genuine  white  cancer,  or  it  contains  pigment-cells,  which  vary  in  arrange- 
ment and  number;  in  the  latter  case  it  is  brown  or  black,  spotted  or 


THE    MAMMARY    GLANDS.  253 

striated,  or  black  throughout  (cancer  melanodes).  It  occasionally  is  com- 
bined with  the  formation  of  cysts,  the  latter  being  either  developed  on 
the  free  surface  of  the  peritoneal  sheath  of  the  ovary,  or  underneath  the 
latter,  and  in  the  peripheral  layers  of  the  stroma. 

This  variety  occurs  in  complication  with  peritoneal  cancer,  with  uterine, 
mammary,  and  ventricular  cancer,  with  cancer  of  the  lymphatic  glands 
and  the  rectum,  and  universal  cancerous  deposit.  Close  adhesions  are 
sometimes  formed  between  it  and  the  adjoining  cancerous  rectum,  so  that 
there  is  often  considerable  difficulty  in  ascertaining  which  of  the  two 
organs  is  the  primary  seat  of  disease.  Both  ovaries  are  very  often  affected. 

In  the  second  variety,  racemose,  fimbriated,  fibrous,  vascular  excre- 
scences, containing  a  milky  or  creamy  juice,  or  an  encephaloid  pulpy 
mass,  form  on  the  internal  surface  of  the  peripheral  follicles  of  areolar 
cancer,  or  of  one  of  the  sacs  of  the  compound  cysts,  or  even  upon  the 
internal  surface  of  a  small  primary  cyst.  They  are  often  very  numerous 
and  attain  a  considerable  length ;  they  become  condensed  into  large 
masses,  and  after  perforating  the  parietes  of  the  cyst,  sprout  through  it. 

This  form  is  often,  .though  not  invariably,  coexistent  with  areolar 
cancer  of  the  ovary  or  of  other  organs. 

Y.  Fibrous  cancer  (scirrhus)  occurs  very  rarely  in  the  ovary. 

SECT.   Y. — ABNORMITIES    OF   THE   MAMMARY   GLANDS. 

§  1.  Arrest  and  Excess  of  Formation. — Froriep  has  lately  recorded 
an  extremely  rare  case  of  absence  of  one  of  the  mammary  glands  in  a 
female ;  the  muscles  and  bones  of  the  corresponding  or  right  side  of  the 
thorax  were  imperfectly  developed.  The  mammae  are  found  imperfectly 
developed  in  those  cases  in  which  the  sexual  apparatus  generally  is  de- 
fective, and  where  certain  parts  of  the  latter,  or  the  entire  individual, 
present  an  hermaphroditic  appearance,  approaching  the  male  type.  An 
excess  of  development  occurs  in  various  degrees  and  forms  :  in  the  first 
instance  we  find  an  increase  in  the  number  of  nipples,  one  gland  being 
provided  with  two  or  three ;  or  there  may  be  supernumerary  glands,  a 
third  one  being  placed  under  one  of  the  normal  or  between  the  two  breasts. 
Sometimes  the  accessory  gland  is  situated  externally  in  the  armpit,  or 
there  may  even  be  a  third,  fourth,  and  fifth,  which  are  arranged  symme- 
trically under  the  normal  breasts,  and  are  always  smaller  than  the  latter. 
We  include  under  this  head  also,  the  precocious  development  of  the 
mammae  in  premature  puberty,  as  well  as  the  development  occasionally 
found  in  the  mammae  of  man  approaching  the  female  character,  either 
with  or  without  an  arrest  of  development  in  the  genital  organs.  An  ex- 
cess of  development  is  occasionally  simulated  by  the  gland  being  sepa- 
rated into  several  lobes. 

§  2.  Anomalies  of  Size. — In  addition  to  the  anomalies  spoken  of  at 
the  end  of  the  preceding  section,  we  here  allude  to  the  increase  in  the 
size  of  one  or,  more  commonly,  of  both  breasts,  developed  spontaneously 
or  after  sexual  excitement  in  either  sex,  or  in  the  female  sex  after  par- 
turition. It  consists  in  a  hypertrophy  of  the  gland  and  of  the  surround- 
ing fat.  The  enlargement  may  attain  a  most  extravagant  extent,  so  as 


254  ABNOEMITIES    OF 

even  to  overwhelm  the  powers  of  growth  in  other  parts.  Hypertrophy 
of  the  gland  is  very  often  introduced  by  violent  congestion,  and  accom- 
panied by  a  secretion  of  milk. 

A  diminution  or  atrophy  of  the  gland,  as  a  morbid  process,  occurs  in 
the  shape  of  premature  involution,  both  in  consequence  of  the  effects  of 
over-nursing,  as  well  as  from  the  sexual  functions  being  completely  in 
abeyance. 

§  3.  Diseases  of  Tissue. 

1.  Inflammation. — Inflammation  of  the  mammary  gland  occurs  very 
rarely,  except  in  consequence  of  various  causes  that  operate  during  the 
puerperal  state,  and  during  suckling. 

The  gland  is  never  attacked  throughout,  but  the  inflammation  appears 
at  distinct  spots  of  various  dimensions,  or  is,  as  it  were,  reduced  to  them 
in  the  course  of  its  progress  ;  and  whilst  it  is  here  developed  with  greater 
intensity,  becomes  moderated  and  recedes  at  all  other  points.  Its  symp- 
toms are,  besides  tumefaction  of  the  gland  at  the  seat  of  disease,  conges- 
tion and  reddening,  by  which  the  natural  appearance  of  the  gland  is  ob- 
literated, and  made  to  resemble  flesh :  there  is  also  hardness  and  resis- 
tance, with  increased  density  of  the  parenchyma,  which  has  lost  its 
toughness,  and  has  become  friable  and  lacerable.  The  gland  is  infil- 
trated with  a  coagulable  product,  containing  more  or  less  reddish  serum. 
Cure  may  ensue  by  resolution  or  absorption  of  the  product,  or  the  pro- 
cess may  pass  into  more  or  less  considerable  induration,  which  at  times 
is  very  obstinate,  or,  again,  it  may  terminate  in  suppuration  or  abscess 
of  the  gland. 

Inflammation  of  the  mammary  gland  not  unfrequently  coexists  with 
one  of  the  above-described  puerperal  diseases,  though  there  is  no  essen- 
tial relation  between  the  two  affections.  The  resulting  abscess  is  to  be 
carefully  distinguished  from  the  deposition  of  pus,  consequent  upon  its 
absorption  in  metrophlebitis. 

2.  Cirrhosis  of  the  mammary  gland. — There  is  a  certain  condition  of 
the  breast  which,  from  all  that  we  know  of  it,  seems  comparable  to  cir- 
rhosis of  the  liver  and  the  lungs  (bronchial  dilatation).     We  have  been 
unable  to  ascertain  whether  any  particular  disease  gives  rise  to  it,  but 
there  is  every  reason  to  suppose  that  it  is  the  result  of  protracted  suck- 
ling. 

3.  Adventitious  groivths. — A  great  variety  of  adventitious  growths 
occur  in  the  mammary  gland ;  some  of  these  are  unusual,  whilst  others 
are  very  frequent.     They  affect  mainly  the  female  breast,  and  only  ex- 
ceptionally, and  from  very  remarkable  influences,  the  male  breast. 

a.  Cysts. — The  simple  cyst,  with  serous,  albuminous,  or  colloid  con- 
tents, as  well  as  the  adipose  cyst,  with  or  without  the  formation  of  hair, 
is  very  uncommon  ;  the  compound  cyst  is  equally  rare.   Not  so,  however, 

b.  Sarcoma. — This  is  of  common  occurrence,  and  it  often  assumes  the 
shape  of  encysted  sarcoma,  the  cysts  being  either  simple,  or  presenting 
the  endogenous  development  of  secondary  cysts ;  this  form  is  the  hydatid 
tumor  or  hydatid  mammary  carcinoma  of  English  writers.     All  the  sar- 
comatous  growths  are  liable  to  attain  a  considerable  size,  they  are  fre- 
quently recognized  as  su-ch,  and  may  be  extirpated  successfully. 


THE    OVUM.  255 

c.  Fibroid  tumors  and  enchondroma. — These  are  not  frequent ;    we 
have  observed  the  former  a  few  times,  but  only  of  small  dimensions. 
Johann  Miiller  has  seen  one  instance  of  the  latter. 

d.  Tubercle. — According  to  our  own    observations,  tubercle   never 
occurs  in  the  mammary  gland. 

e.  Cancer. — Cancer,  on  the  other  hand,  which  is  found  to  occur  in 
almost  all  its  varieties,  is  the  more  frequent ;  mammary  and  uterine  cancer 
alone  suffice  to  give  to  the  female  sex  a  vast  preponderance  over  the  male 
sex,  as  to  the  frequency  of  cancerous  aifections.      The  different  forms 
may  occur  by  themselves,  or  in  combination  with  one  another ;  medullary 
carcinoma  is  particularly  liable  to  form  upon  a  scirrhous  matrix. 

a.  True  scirrhus,  or  fibrous  cancer,  and  the  following  variety,  are  the 
most  common.  Scirrhus  presents  the  well-known  characters  of  a  carti- 
tilaginoid,  immovable,  nodulated,  branched  tumor,  which  draws  in  the 
integument,  and  more  particularly  the  nipple,  with  its  arcola,  and  is  im- 
bedded in  fat.  Its  internal  structure  presents  a  lobulated  appearance, 
and  consists  of  a  whitish  fibrous  stroma,  and  of  a  gray  transparent  crys- 
talline substance,  which  is  deposited  in  the  interstices  of  the  former.  It 
is  often  traversed  by  lacteal  ducts  which  contain  a  corrugated,  whitish, 
or  yellow  cheesy  matter.  The  ulcer  that  it  gives  rise  to  is  cup-shaped, 
and  presents  a  hard  elevated  margin  and  a  sanious  discharge  ;  extends 
in  all  directions,  but  especially  backwards,  so  as  to  involve  the  pectoral 
and  intercostal  muscles,  the  periosteum  of  their  ribs  and  their  bony 
structure,  and  at  last  to  fix  itself  immovably  in  the  thoracic  parietes. 
The  margin  as  well  as  the  base  of  the  ulcer  degenerate  into  a  red,  vascu- 
lar, bleeding  fungus,  which  is  distended  by  a  whitish  encephaloid  juice  ; 
the  immediate  consequence  is  a  development  of  lardaceo-medullary  tumors 
in  the  most  various  tissues,  either  in  the  vicinity  or  at  a  distance.  This 
constitutes — 

/9.  Medullary  carcinoma,  which  however  occurs  not  only  in  combination 
with  fibrous  carcinoma,  but  also  in  a  primary  form  ;  in  the  latter  case  it 
is  equally  distinguished  by  its  rapid  growth,  its  large  dimensions,  by  the 
much  more  speedy  degeneration  into  universal  cancerous  cachexia,  and 
by  the  sponginess  of  the  ulcer. 

f.  Cancer  hyalinus  is  much  less  frequent  than  either  of  the  former 
varieties  ;  it  occasionally  attains  a  considerable  size,  and  has,  in  addition 
to  other  peculiarities,  a  remarkably  lobulated  structure. 

Cancer  of  the  mammary  gland  is  generally  developed  after  the  thirty- 
fifth,  though  it  is  sometimes  met  with  before  the  thirtieth  year.  It  fre- 
quently exists  by  itself,  but  is  more  commonly  combined  with  cancer  of 
the  adjoining  axillary  glands,  with  mediastinal,  pleuritic,  pulmonic, 
uterine,  hepatic,  and  cerebral  cancer,  with  universal  cancerous  cachexia, 
and  with  mollities  ossium. 

% 

SECT.   VI. — ABNORMITIES   OF  THE   OVUM. 

We  shall  first  discuss  the  anomalies  presented  in  the  attachments  of 
the  ovum,  i.  e.  its  attachment  and  development  at  a  point  external  to  the 
uterine  cavity,  extra-uterine  pregnancy  and  the  degeneration  of  the  ovum. 
We  shall  then  examine  the  abnormities  occurring  in  the  separate  parts 


256  ABNOKMITIES    OF 

of  the  ovum,  the  membranes,  the  placenta,  the  funiculus  umbilicalis,  and 
the  foetus. 

§  1.  Extra-uterine  Pregnancy. — Extra-uterine  pregnancy  may  take 
place  at  different  points ;  in  the  order  of  frequency  these  points  are,  the 
Fallopian  tube,  the  parietes  of  the  uterus,  the  ovary,  and  the  vagina.  We 
proceed  to  state  the  more  important  matters  connected  with  each  of  these 
occurrences. 

1.  Pregnancy  in  the  Fallopian  tube  (graviditas  tubaria)  is  the  most  fre- 
quent of  all ;  the  ovum  attaches  itself  either  near  the  fiinbriated  extremity, 
or  more  towards  the  uterus ;  this  part  of  the  tube  becomes  dilated  into 
an  oval  sac,  with  eccentric  development.      This  variety  of  pregnancy 
generally  proves  fatal  in  the  third  or  fourth  month  by  hemorrhage  into 
the  peritoneal  cavity,  from  rupture  of  the  sac  either  with  or  without  an 
escape  of  the  foetus.     We  have  however  observed  this  occurrence  in  one 
case  at  the  sixth  week,  and  in  another  a  fortnight  after  conception.    On 
the  other  hand,  an  old  preparation  existing  in  the  Viennese  Museum, 
appears  to  prove  that  pregnancy  may  continue  to  the  sixth  or  seventh 
month.    Of  six  cases  of  tubal  pregnancy  preserved  in  the  same  collection, 
five  are  on  the  right  side. 

2.  Pregnancy  in  the  parietes  of  the  uterus. — This  kind  of  pregnancy, 
which  has  also  received  the  name  of  interstitial  pregnancy,  and  about  the 
seat  of  which  various  opinions  have  been  promulgated,  is  probably  nothing 
more  than  a  pregnancy  of  the  Fallopian  tube,  i.  e.  a  pregnancy  occurring 
in  that  portion  of  the  tube  which  traverses  the  uterine  tissue.     It  is,  con- 
sequently, in  a  close  relation  with  the  uterus,  and  necessarily  involves 
the  uterine  parenchyma  in  such  a  manner  that  the  cavity  which  contains 
the  foetus  with  its  membranes,  appears  to  have  been  developed  within  the 
tissue  of  the  uterus.     It  will  consequently  be  most  appropriate  to  consi- 
der it  as  tubo-uterine  pregnancy.     The  pregnant  sac  consists  of  uterine 
tissue,  its  walls  are  of  considerable  thickness,  and  are  in  direct  connection 
with  the  uterus  ;  the  sac  is  more  or  less  distinctly  seated  at  the  side  of 
the  fundus  uteri,  and  uterine  fibres  are  traceable  into  it. 

This  pregnancy  generally  proves  rapidly  fatal  by  rupture  ;  however,  it 
is  evident,  both  from  our  own  observations  and  those  of  other  morbid 
anatomists,  that  it  may  terminate  in  a  different  manner.  At  various 
periods  of  the  normal  progress  of  pregnancy,  the  sac,  probably  in  conse- 
quence of  the  traction  exerted  upon  it,  becomes  the  seat  of  chronic  in- 
flammation, which  passes  into  suppuration  and  gangrene  ;  after  causing 
the  death  of  the  foetus,  this  either  proves  fatal  by  itself  or  by  inducing 
peritonitis.  The  sac  may  suppurate  chiefly  in  one  direction,  and  thus 
involve  th  eadjoining  viscera ;  so  that,  after  their  destruction,  it  may  dis- 
charge its  contents  externally  or  into  the  cavities  of  neighboring  organs  ; 
this  is  generally  ejected  slowly  and  piecemeal.  In  other  cases,  preg- 
nancy not  only  attains,  but  even  extends  beyond  the  full  period.  The 
parietes  of  the  sac  in  this  case  are  of  considerable  substance  and  thick- 
ness ;  the  sac  itself  is  capacious,  and  contains  a  mature  or  even  an  over- 
ripe hypertrophied  foetus.  In  one  case  of  this  description  the  pregnancy 
lasted  sixteen  months,  and  the  over-ripe  foetus,  which  had  died  some  time 
previously,  was  extracted  by  opening  the  abdominal  cavity  and  the  sac. 


THE    OVUM.  257 

3.  Peritoneal   pregnancy,  graviditis  peritonealis,    occurs  within   the 
cavity  of  the  peritoneum  ;  the  foetus  with  its  membranes  is  surrounded  by 
an  organic  exudation  attached  to  the  peritoneum,  and  the  placenta  is 
found  connected  with  the  most  different  parts  of  the  parietal  and  visceral 
laminae  of  the  peritoneum.     This  form  of  pregnancy  generally  terminates 
fatally  at  various  periods  by  peritoneal  inflammation  ;  sometimes  the  peri- 
tonitis ends  in  suppuration,  which  may  cause  the  effete  foetus,  together 
with  the  formative  organs,  to  be  discharged  by  various  passages. 

4.  Ovarian  pregnancy  is  the  most  unfrequent  form  of  the  extra-uterine 
pregnancy ;  it  either  terminates  in  laceration,  which  is  at  once  fatal,  or 
in  inflammation  and  suppuration  of  the  sac,  which  in  their  turn  prove 
fatal,  or  cause  a  diminution  of  the  foetus. 

5.  Vaginal  pregnancy  is  not  only  the  rarest  of  all,  but  altogether  pro- 
blematical. 

Although  we  have  given  an  anatomical  account  of  the  chief  termina- 
tions occurring  in  extra-uterine  pregnancy,  we  will  add  a  comparative 
analysis,  and  also  subjoin  one  that  we  have  not  yet  mentioned. 

Interstitial,  ovarian,  and  tubal  pregnancy  terminate  by  laceration ;  the 
last  two  at  an  early  period,  the  first  much  later,  and  even  after  the  usual 
duration  of  pregnancy. 

All  the  varieties  of  extra-uterine  pregnancy  may  terminate  in  inflam- 
mation with  consequent  suppuration,  owing  to  the  decomposition  of  the 
defunct  foetus,  and  the  putrescence  of  its  involucra.  Inflammation  may, 
in  advanced  interstitial  pregnancy,  doubtless  arise  in  the  sac  primarily, 
from  the  traction  exerted  upon  its  tissue  and  upon  the  peritoneal  invest- 
ment, and  thus  induce  the  death  of  the  foetus.  If  the  suppurative  pro- 
cess attacks  the  organs  adjoining  and  adherent  to  the  sac,  the  latter  may 
discharge  itself  externally  through  the  abdominal  parietes  or  into  the 
cavity  of  an  adjoining  organ ;  the  foetus  may  thus  be  eliminated  entire 
or  piecemeal,  in  a  state  of  maceration,  saponification,  or  putrefaction. 
This  has  been  observed  repeatedly ;  single  bones  belonging  to  the  foetus 
having  been  seen  to  pass  through  the  navel,  at  different  parts  of  the  hy- 
pogastric  region,  and  still  more  frequently  by  the  anus  or  the  urinary 
passages.  It  is  stated  that,  after  this  has  taken  place,  a  cure  may  follow ; 
but  death  from  exhaustion  is  a  more  common  consequence.  The  dis- 
charge may  occur  long  after  the  usual  period  of  pregnancy  has  termi- 
nated. 

Besides  the  above-mentioned  modes  of  termination  there  is  another, 
which  must  be  viewed  as  the  most  favorable  one  ;  in  this  case  the  foetus 
dies  before  or  after  it  has  attained  maturity,  and,  after  the  surrounding 
fluids  have  been  removed  by  absorption,  becomes  mummefied  and  indu- 
rated ;  or  if  the  soft  tissues  have  already  undergone  a  certain  degree  of 
decomposition,  it  may  become  incrusted  by  a  greasy,  chalky  substance 
(lithopasdion),  and  in  this  shape  be  borne  for  a  long  time  in  the  con- 
tracted sac,  without  much  inconvenience.  This  termination  occurs  chiefly 
in  peritoneal  pregnancy,  it  has  however  also  been  observed  in  pregnancy 
in  the  Fallopian  tube. 

In  all  extra-uterine  pregnancies  we  commonly  observe  the  forma- 
tion of  a  deciduous  membrane  on  the  inner  surface  of  the  uterus ;  and 
the  latter  undergoes,  up  to  a  certain  period,  the  same  changes  that  it 

VOL.  II.  17 


258  ABNORMITIES    OF 

would  present  if  it  contained  the  foetus.  It  scarcely  ever  exceeds  the 
dimensions  which  it  exhibits  about  the  first  and  second  month  of  normal 
pregnancy.  This  development  of  the  uterus  is  undoubtedly  more  consi- 
derable in  interstitial  and  tubal  pregnancy,  than  in  the  other  varieties 
of  extra-uterine  pregnancy,  and  may  be  considered  as  analogous  to  the 
development  of  the  unimpregnated  half  of  the  uterus  bicornis  or  bilocu- 
laris. 

§  2.  Degeneration  of  the  Ovum. — We  here  but  allude  to  those  cases  of 
degeneration  of  the  ovum  which  are  called  moles,  and  which  are  dis- 
tinguished according  to  their  external  appearance,  structure,  and  density 
as  carneous,  vesicular  moles,  &c.  We  exclude  all  abnormities  in  the  for- 
mation of  the  foetus,  and  remark  that  moles  generally  contain  no  foetus, 
as  the  degeneration  of  the  membranes  and  the  placenta  mostly  occurs  at 
a  very  early  period  of  pregnancy,  in  consequence  of  which  the  embryo 
dies  and  disappears,  the  cavity  of  the  amnios  remaining  persistent  or  be- 
coming obliterated.  The  diseases  in  which  the  moles  of  which  we  speak 
originate,  will  be  adverted  to  in  the  following  pages,  and  we  shall  take 
care  to  point  out  the  connection. 

§  3.  Abnormities  of  the  separate  parts  of  the  Ovum. 

1.  Abnormities  of  the  Membranes  and  of  the  Liquor  Amnii. — The  mem- 
branes of  the  ovum  may  undoubtedly  become  the  seat  of  hemorrhage  and 
inflammation  at  a  very  early  period  of  pregnancy ;  these  affections  are 
probably  the  cause  of  the  formation  of  moles,  but  they  may  also  give  rise 
to  abortion.  The  dirty  white  and  ash-colored  spots  occurring  in  various 
sizes  upon  the  amnion,  and  accompanied  by  thickening  of  the  membranes, 
and  the  opacity  sometimes  affecting  the  greater  part  of  the  amnion,  evi- 
dence previous  inflammation.  But  under  this  head  we  must  more  parti- 
cularly instance  the  deposits  of  a  grayish-red,  whitish,  or  yellowish  sub- 
stance, occurring  on  the  chorionand  the  decidua,  in  the  shape  of  patches. 
The  membranes  here  present  a  thickening  without  distinct  edges,  or  flat- 
tened rounded  nodules  ;  the  tissues  being  either  softened  and  friable,  or 
indurated  and  dense.  Occasionally  the  membranes,  in  consequence  of  a 
cretification  of  the  deposit,  are  incrusted,  or  contain  a  chalky  grit. 

The  albuminoid  layer  which  represents  the  so-called  tunica  media,  is 
not  unfrequently  morbidly  increased  in  quantity ;  sometimes  a  thin, 
brawny,  or  watery  accumulation  is  substituted  for  it,  and  to  the  latter  the 
discharge  of  the  so-called  spurious  liquor  amnii  in  the  second  half  of  preg- 
nancy, is  probably  due  (hydrallantois).  In  other  cases  its  amount  is 
very  small,  or  it  presents  greater  consistency,  and  may  even  be  tough  and 
membranous. 

The  villi  of  the  chorion  degenerate  at  an  early  period  of  pregnancy, 
into  pedunculated  vesicles  or  cysts,  which  are  placed  at  their  extremities  ; 
a  degeneration  which  is  also  seen  in  the  placenta  ;  when  occurring  in  an 
extensive  and  advanced  degree  they  represent  what  has  been  termed  the 
vesicular  or  hydatid  mole. 

Occasionally  we  discover  more  or  less  extensive  adhesions  between  the 
embryo  and  the  amnion,  which  is  a  circumstance  of  some  importance,  on 
account  of  the  impediment  it  offers  to  the  proper  development  of  the 
foetus. 


THE    PLACENTA.  259 

The  liquor  amnii  is  sometimes  so  much  reduced  in  quantity,  that  the 
foetus  is  closely  invested  by  the  amnion,  at  others  it  is  excessive  (hydram- 
nios) ;  it  is  also  found  more  or  less  opaque,  discolored,  and  fetid. 

2.  Abnormities  of  the  Placenta. — «.  The  placenta  offers  considerable 
variations  as  to  size,  without  being  morbidly  affected.  We  have  here 
only  to  mention  that  extreme  development  of  the  intervascular  substance 
of  the  decidua  which  compresses  the  vessels ;  as  well  as  the  occurrence 
of  atrophy  with  relaxation,  a  contraction  accompanied  by  coriaceous 
toughness,  the  causes  and  original  seat  of  which  doubtless  vary,  but  with 
the  exception  of  inflammation  are  unknown. 

/?.  The  placenta  presents  no  remarkable  pathological  changes  in  point 
of  form,  with  the  exception  of  its  division  into  a  few  large  or  numerous 
smaller  lobules.  The  various  shapes  presented  by  the  placenta  offer  no 
interest  in  reference  to  pathology. 

Y.  The  placenta  presents  numerous  deviations  in  regard  to  position  ; 
its  position  at  the  inferior  segment  of  the  uterus  deserves  particular  men- 
tion, as  its  eccentric  or  concentric  development  at  the  os  uteri  induces 
considerable  perils  towards  the  end  of  pregnancy,  by  giving  rise  to  fre- 
quent and  lasting  hemorrhage. 

d.  Allied  to  this  hemorrhage  are  the  floodings  which,  though  the  pla- 
centa occupies  its  normal  position,  are  brought  on  by  concussion  or  con- 
tusion of  the  pregnant  womb,  inducing  a  forcible  separation  of  the  pla- 
centa from  the  uterus,  or  a  laceration  of  the  former,  or  which  are  the 
result  of  rupture  of  the  uterine  vessels  of  the  placenta  caused  by  extreme 
congestion.     Whether  or  not  accompanied  by  external  bleeding,  they 
represent  apoplexy  of  the  placenta,  one  of  the  most  frequent  causes  of 
abortion  ;  the  blood  may  be  diffused  through  the  parenchyma  to  a  greater 
or  less  extent,  or  be  extravasated  and  accumulated  at  one  spot,  which 
may  either  adjoin  the  uterine  parietes  or  be  situated  deeply  within  the 
placental  tissue.     The  placenta  is  undoubtedly  sometimes  affected  with 
plethora,  congestion,  and  diminution  in  the  rapidity  of  the  circulation,  a 
condition  which  is  important  on  account  of  the  impeded  vivification  of 
the  foetal  blood.     It  is  then  of  a  darker  color,  externally  and  internally 
of  a  dark  violet  or  livid  hue,  the  vessels  are  overcharged,  the  entire  organ 
appears  enlarged  and  heavier,  and  feels  harder  and  denser. 

e.  Among  the  textural  diseases  inflammation  is  the  most  frequent ;  it 
generally  occurs  in  the  lobular  form,  as  it  attacks  small  sections  or 
lobules,  and  rarely  larger  portions  of  the  placenta.     Still  a  considerable 
portion  may  be  simultaneously  or  successively  attacked  even  in  the  first 
instance,  inasmuch  as  the  products  of  the  process  are  found  scattered 
over  numerous  spots.     It  recurs  at  different  or  new  points  to  the  end  of 
pregnancy  ;  an  opportunity  is  thus  presented  of  observing  it,  if  not  in  its 
first  stage,  at  least  shortly  after  the  formation  of  the  product,  and  of 
tracing  the  metamorphoses  of  the  latter. 

Inflammation  of  the  placenta  generally  gives  rise  to  a  plastic  fibrinous 
deposit,  which  is  reddened  by  the  coloring  matter  of  the  blood  which  it 
contains,  and  by  which  the  diseased  portion  is  rendered  denser  and  more 
lacerable.  This  may  be  termed  hepatization  of  the  placenta  ;  it  may  be 
recognized  by  the  increased  resistance  and  nodulated  tumefaction  pre- 


260  ABNORMITIES    OF 

sented  to  the  touch.  In  the  course  of  time  the  deposit  assumes  a  pale 
red,  grayish  or  yellowish-red,  or  even  yellowish-white  tinge ;  at  the  same 
time  it  becomes  firmer,  and  together  with  the  included  obliterated  tissue, 
contracts  and  shrivels.  The  inflammation  has  thus  terminated  as  it 
usually  does,  in  induration  and  obliteration  of  the  placental  tissue,  which 
is  converted  into  an  ashy,  tough,  leathery  callus,  resembling  elastic  tissue. 

It  appears  an  established  fact  that  an  adhesion  may  form  between  the 
placenta  and  the  uterus  in  consequence  of  a  process  of  this  kind ;  the 
extent  as  well  as  the  intimacy  of  the  union  naturally  varies. 

In  rare  cases  the  inflammation  may  give  rise  to  a  purulent  product, 
causing  suppuration  of  the  placenta  in  the  shape  of  circumscribed  globu- 
lar abscesses,  or  of  diffused  infiltration  and  fusion  of  the  placental  tissue 
— phthisis  placentae. 

The  question  as  to  the  seat  of  the  inflammatory  process,  or  rather  as 
to  which  of  the  vascular  systems  is  affected,  has  not  as  yet  been  answered ; 
doubtless  either  of  the  two  may  be  involved,  and  it  is  to  be  presumed 
that  in  both  cases  the  results  will  be  the  same,  on  account  of  the  intimate 
connection  existing  between  them. 

Inflammation  and  consequent  obliteration  of  the  placenta  are  the  more 
likely  to  induce  imperfect  nutrition,  and  consequent  tabes  of  the  foetus, 
the  more  they  are  diffused  and  the  greater  the  number  of  placental  sec- 
tions attacked  at  the  same  time. 

The  foetal  portion  of  the  placenta,  as  we  have  already  mentioned  when 
speaking  of  the  villi  of  the  chorion,  is  not  unfrequently  attacked  by  a 
degeneration  in  the  shape  of  round  or  oval,  fusiform,  pedunculated,  serous 
vesicles  or  hydatids,  which  diminish,  and  even  entirely  obliterate  the 
cavity  of  the  amnion.  This  is  a  vesicular  or  hydatid  mole,  Laennec's 
acephalocystis  racemosa. 

Foreign  observers  have  given  instances  of  osseous  deposits  in,  or  ossi- 
fication of  the  placenta ;  they  are  gibbous,  nodulated,  or  cordate  forma- 
tions, which  are  probably  developed  in  the  placental  tissue  after  it  has 
been  obliterated  by  inflammation,  or  in  the  fibrinous  coagula  caused  by 
hemorrhages. 

Tubercle  does  not  occur  in  the  placenta ;  one  must  be  careful  not  to 
confound  the  product  of  inflammation,  which  sometimes  has  a  cheesy,  fria- 
ble, and  chalky  appearance,  or  a  fibrinous  coagulum  caused  by  hemor- 
rhage, which  is  undergoing  a  similar  metamorphosis,  with  placental 
tubercle. 

The  observations  recorded  of  scirrhus,  or  scirrhous  degeneration  of  the 
placenta,  may  justly  be  considered  as  erroneous ;  the  cases  described  as 
such,  are  obliterations  of  the  placental  tissue  after  inflammation,  indu- 
rated inflammatory  products,  or  old,  shrivelled,  decolorized  extravasations 
of  blood,  &c.  Adhesions  similar  to  those  which  we  mentioned  when 
speaking  of  the  membranes,  are  found  to  occur  between  the  placenta  and 
the  foetus. 

3.  Abnormities  of  the  Umbilical  Cord. — The  instances  of  absence  of 
the  funiculus  umbilicalis,  recorded  by  ancient  writers,  must  evidently,  as 
Meckel  has  pointed  out,  be  considered  as  cases  of  extreme  shortness  of 
the  cord.  The  subject  is  of  considerable  importance  on  account  of  its 


THE    FCETUS.  261 

influence  upon  arrest  of  development,  particularly  of  the  inferior  half  of 
the  foatus. 

The  cord  varies  considerably  in  length.  Davis  has  seen  one  of  two, 
Montault  of  four,  Meissner  and  myself  of  five  inches  only ;  whilst  on  the 
other  hand,  Baudelocque  has  noticed  one  of  forty-six,  and  Heriter  one 
of  fifty-seven  inches.  In  the  Viennese  Museum  there  is  a  cord  attached 
to  a  large  placenta,  which  measures  fifty-four  inches  ;  and  if  we  allow 
five  or  six  inches  for  the  distance  at  which  it  was  probahly  severed  from 
the  navel,  the  whole  cord  must  have  been  from  fifty-nine  to  sixty  inches 
in  length. 

The  chief  deviations  as  to  the  insertion  of  the  cord  are  the  marginal 
attachment,  and  the  insertion  external  to  the  placenta  into  the  mem- 
branes. Occasionally  we  notice  a  premature  separation  of  the  vessels, 
and  of  the  two  arteries ;  one  not  unfrequently  is  absent,  and  the  other  is 
then  commonly  a  direct  continuation  of  the  abdominal  aorta. 

The  true  knots  of  the  umbilical  cord  that  occur  in  rare  cases,  are  of 
importance,  as  they  may  occasion  obstacles  to,  or  a  cessation  of,  the  cir- 
culation, in  consequence  of  the  traction  exerted  upon  them  during  par- 
turition. 

Irregularities  in  the  position  of  the  umbilical  cord  very  frequently  pre- 
sent themselves  in  the  shape  of  circumvolutions  round  different  parts  of 
the  foetus  ;  if  traction  is  exerted  upon  them,  the  circulation  may  be  im- 
peded in  the  cord,  as  well  as  in  the  part  of  the  fcetus  which  they  surround. 

Rupture  of  the  umbilical  cord,  or  of  its  component  vessels,  and  espe- 
cially of  the  vein,  are  of  very  rare  occurrence.  They  result  from  extreme 
traction,  when  the  cord  is  either  too  short  or  twisted. 

Adhesions  have  been  noticed  in  rare  cases  between  the  funiculus 
umbilicalis,  and  the  fcetus  and  the  membranes. 

The  gelatinous  matter  of  the  cord  is  either  excessive,  and  the  latter 
then  appears  much  enlarged ;  or  it  is  diminished  in  quantity,  in  which 
case  the  cord  is  thin,  flabby,  and  corrugated. 

The  umbilical  vein  presents  varicose  dilatations  and  contractions,  the 
latter  particularly  in  the  vicinity  of  the  navel.  The  sheath  of  the  cord 
occasionally  contains  serous  cysts. 

4.  Abnormities  of  the  Foetus. — We  pass  over  those  deviations  of  con- 
genital development  which  we  have  already  discussed,  and  devote  this 
section  to  the  consideration  of  the  remaining  anomalies,  although  we 
have  already  cursorily  touched  upon  most  of  them. 

We  not  unfrequently  meet  with  a  hypertrophy  of  the  foetus,  or  of 
individual  organs  and  sections  of  the  fcetal  body.  Children  are  some- 
times born,  either  at  the  proper  period  or  later,  of  excessive  dimensions, 
'over-nourished  and  endowed  with  all  the  characters  of  over-ripeness. 
Among  the  partial  hypertrophies  we  have  to  specify  those  of  the  brain, 
of  the  thyroid  and  thymus  glands,  the  hypertrophy  of  certain  parts  of 
the  skeleton,  as  the  premature  development  of  the  cranium,  the  excess  in 
the  digital  phalanges  of  the  hands  or  feet,  the  so-called  hypertrophies  of 
the  liver  and  the  spleen. 

The  entire  fcetus  may  be  atrophic,  in  consequence  of  the  cachectic 
state  of  the  mother ;  but  those  cases  are  of  greater  importance  which  re- 
sult from  disease  of  the  membranes,  the  placenta,  and  the  cord ;  and  if 


262  ABNORMITIES    OF 

occurring  at  the  earliest  period  of  embryonic  life,  may  cause  the  embryo 
to  disappear  entirely,  or  so  far  as  to  leave  but  mere  traces.  Partial 
atrophy,  as  a  result  of  disease  in  the  nervous  centres,  occasionally  affects 
the  extremities ;  in  rare  cases,  it  may  be  the  consequence  of  pressure  ex- 
erted by  the  uterus  on  the  funiculus  umbilicalis. 

The  most  various  curvatures  and  malpositions  of  the  bones  (pes 
equinus),  curvatures  and  dislocations  of  the  joints,  maybe  brought  on  by 
contraction  of  the  uterine  cavity,  external  pressure,  convulsions,  and 
tonic  spasms  of  the  foetus.  Convulsions  or  traumatic  injuries  may  induce 
fractures  of  the  bones,  and  even  rupture  of  the  abdominal  viscera,  and 
especially  of  the  liver  and  the  intestines. 

To  these  lesions  of  continuity  we  have  to  add  the  spontaneous  ampu- 
tations of  extremities  (Simpson,  Montgomery),  occurring  at  an  early 
stage  of  embryonic  life  ;  they  have  not  as  yet  been  sufficiently  accounted 
for,  and  are  to  be  carefully  distinguished  from  cases  of  arrest  of  develop- 
ment. 

The  foetus  may  be  affected  by  general  plethora,  as  well  as  by  conges- 
tion of  separate  organs,  which  ultimately  degenerates  into  hemorrhage 
and  apoplexy.  The  brain  and  spinal  marrow  and  their  membranes,  the 
thyroid  gland,  the  liver,  the  kidneys,  and  the  suprarenal  capsules  are 
particularly  liable  to  be  attacked. 

A  most  important  morbid  process  and  one  of  very  frequent  occurrence, 
the  peculiarities  of  which  in  the  foetus  are  almost  unknown,  is  inflamma- 
tion. Its  terminations  and  consequences  are  of  great  value  in  regard  to 
the  doctrine  of  deviations  of  formations,  for  a  reconstruction  of  which  we 
are  particularly  indebted  to  Simpson,  whose  views  on  the  subject  are  of 
peculiar  interest.  Inflammation  attacks  almost  all  the  organs,  including 
those  peculiar  to  foetal  life,  the  thymus,  and  the  suprarenal  capsules. 
Its  terminations  and  consequences  the  more  resemble  those  which  it  pre- 
sents in  the  infant  and  adult,  the  more  mature  the  foetus,  the  more  de- 
veloped the  tissues  attacked,  are.  It  gives  rise  to  plastic  products  with 
adhesions  between  adjoining  organs,  accompanied  by  the  most  various 
new  formations ;  it  induces  suppuration  and  suppurative  destruction, 
though  very  rarely  induration.  On  the  other  hand,  it  causes  in  very 
delicate  embryos,  and  in  particular  tissues  of  peculiar  delicacy,  a  very 
rapid  dissolution,  or  liquefaction,  either  of  a  benignant  or  a  malignant 
character. 

Dropsy  of  the  different  cavities  and  anasarca,  have  been  noticed  in  the 
foetus ;  among  the  former,  hydrocephalus  and  hydrorrhachis  are  both  in 
themselves,  and  on  account  of  the  consequent  arrest  of  development  and 
the  malformation  of  the  cranium  and  of  other  parts,  of  chief  importance. 
Cutaneous  dropsy  sometimes  attacks  the  foetus  in  a  very  eminent  degree, 
and  is  generally  combined  with  dropsical  accumulations  in  the  large 
cavities.  It  has  been  particularly  and  repeatedly  observed  in  the  chil- 
dren born  of  women  who  had  themselves  suffered  from  dropsy  during 
pregnancy  (West) ;  it  also  occurs  under  other  circumstances,  and  in  these 
cases  probably  originates  in  obstacles  to  the  circulation  through  the  um- 
bilical vessels  and  the  foetal  portion  of  the  placenta. 

Even  adventitious  growths  occur,  though  rarely,  in  the  foetus ;  we  oc- 
casionally discover  cysts,  particularly  the  simple  cyst,  lipomatous,  sarco- 
matous,  and  even  cancerous  products.  Although  many  of  the  cases  that 


THE    FCETUS.  263 

have  been  considered  as  cancerous,  rest  upon  a  misapprehension,  the  oc- 
currence of  carcinoma  is  undoubted  and  of  peculiar  interest.  Foetal 
cancer  is  allied  to  the  cancer,  and  especially  to  the  medullary  variety, 
occurring  during  infancy  ;  we  communicate  the  following  case  that  we 
have  ourselves  observed,  as  one  of  peculiar  interest. 

A  female  infant,  of  16J  inches  in  length,  and  27  days  old,  presented 
in  the  region  of  the  pudenda,  anus,  and  sacrum,  a  tumor  tensely  invested 
by  the  cutaneous  covering.  It  was  of  the  size  of  a  goose's  egg,  and  had, 
towards  the  sacral  and  lower  lumbar  vertebrae,  a  conoid  process  of  the 
size  of  a  hazel-nut.  On  its  left  side  were  noticed  the  vaginal  and  anal 
opening,  which  were  pushed  downwards  and  separated,  the  latter  appear- 
ing in  the  shape  of  an  excoriated  semilunar  fissure.  The  child  was  born 
with  this  tumor.  It  lay  external  to  the  pelvis,  under  the  skin  and  the 
perineal  muscles ;  posteriorly,  fibres  of  the  glutrcus  magnus  spread  over 
it.  It  was  surrounded  by  a  fibrous  sheath,  and  consisted  of  various 
tissues  ;  the  inferior  third,  and  the  portion  that  lay  more  to  the  right, 
resembled  the  reddish-gray  cerebral  substance  of  an  infant's  brain, 
whereas  the  two  upper  thirds  presented  a  follicular  tissue  with  small 
loculi,  containing  a  grayish  gelatine.  The  tumor  extended  into  the 
pelvis  by  the  inferior  aperture,  in  the  shape  of  an  oval  serous  cyst  of  the 
size  of  a  walnut,  the  internal  surface  of  which  appeared  here  and  there 
to  contain  a  black  pigment,  and  presented  a  few  ridge-like  duplicatures. 
The  follicular  portion  of  the  morbid  product  also  forced  its  way  through 
the  sacral  fissure  into  the  medullary  canal,  and  then  presented  a  process 
closely  resembling  the  external  conical  process,  except  that  it  was  smaller. 

This  adventitious  product  is  nothing  more  than  a  combination  of 
areolar  and  medullary  cancer,  the  circumference  of  which  is  converted 
into  a  cyst. 

Tubercle  occurs  but  in  very  rare  cases  in  the  foetus ;  we  ourselves  have 
never  observed  it. 

The  foetal  fluids  are  undoubtedly  liable  to  numerous  acute  and  chronic 
morbid  affections,  as  is  evidenced  by  the  occurrence  of  various  exanthe- 
matic  and  impetiginous  diseases,  as  well  as  cachectic  disorders,  such  as 
rickets,  syphilis,  tubercle,  peculiar  hypertrophies  of  the  liver,  the  spleen, 
the  lymphatic  glands. 

Variola,  measles,  and  various  cicatrices  have  been  noticed  on  the  foetal 
integuments.  To  this  head  also  pertains  pemphigus  and  various  vesicular 
eruptions,  the  vesicles  of  which  contain  a  livid,  sero-purulent  fluid,  are 
converted  into  ulcers,  and  may  be  traced  to  syphilitic  causes.  We  also 
find  ecchymoses,  petechial  suffusions  of  tbe  skin,  shallow  or  elevated  nsevi, 
of  a  brown  or  livid  hue,  and  of  different  sizes.  The  subcutaneous  cellular 
tissue  is  the  seat  of  anasarca  and  of  many  of  the  above-mentioned  tumors 
and  morbid  growths ;  shortly  after  birth,  it  is  frequently  attacked  with 
induration. 

The  serous  membranes  are  found  more  frequently  inflamed  than  any 
other  tissue,  or  the  previous  existence  of  inflammation  in  them  is  evi- 
denced by  adhesions  of  the  organs  which  they  invest ;  these,  undoubtedly, 
give  rise  to  many  of  the  anomalies  in  the  position  of  these  organs,  which 
are  in  part  at  least  looked  upon  as  the  consequence  of  original  malfor- 
mation and  arrest  of  development. 

Peritoneal  inflammation  is,  doubtless,  the  most  frequent,  and  it  is  upon 


264  ABNORMITIES    OF 

this  fact  and  upon  the  adhesive  termination  of  the  disease,  that  Simpson 
bases  his  views  regarding  many  of  the  anomalies  that  are  commonly  con- 
sidered as  cases  of  arrest  of  development.  Inflammation  of  the  pleura 
and  pericardium  are  less  frequent. 

Among  the  mucous  membranes,  that  of  the  alimentary  tube  is  the  chief 
seat  of  disease,  as  we  shall  have  occasion  to  explain  more  fully  in  the 
sequel. 

In  addition  to  the  above-mentioned  fractures,  dislocations,  and  spon- 
taneous amputations,  we  find  the  osseous  system  liable  to  suppurative 
inflammation  (caries),  hyperostosis,  and  an  exuberant  deposit  of  callus, 
an  arrest  in  the  process  of  ossification,  which  is  allied  to  rhachitism 
(rhachitis  congenita). 

The  morbid  processes  in  the  muscular  system  which  we  chiefly  meet 
with,  are  contractions ;  they  depend  mainly  upon  diseases  of  the  nervous 
centres. 

The  heart  is  liable  to  be  affected,  in  the  first  instance,  by  pericarditis ; 
in  the  second,  by  endocarditis.  It  is  very  remarkable,  that  the  relation 
of  the  latter  to  the  cavities  of  the  heart  is  the  reverse  of  what  occurs 
after  birth.  The  dilatations  and  valvular  afiections  observed  at  the  left 
ventricle  and  its  arterial  orifice  in  the  adult,  as  a  consequence  of  endo- 
carditis, are  here  found  to  attack  the  right  ventricle  and  the  valves  of 
the  pulmonary  artery. 

The  stenoses  observed  in  the  latter,  which  originate  in  a  morbid  me- 
tamorphosis of  the  valves,  are  to  be  carefully  distinguished  from  cases  of 
arrest  of  development  occurring  here,  especially  in  the  shape  of  atrophy 
of  the  pulmonary  artery,  resulting  from  anomalies  in  the  structure  of  the 
heart. 

The  ductus  Botalli  is  in  rare  cases  liable  to  an  aneurismatic  dilatation, 
and  in  this  respect  resembles  the  aorta  in  extra-uterine  life. 

The  brain  and  the  spinal  cord  are  particularly  subject  to  disease  in  the 
foetus ;  and  these  afiections  are  undoubtedly  the  cause  of  many  defects 
and  malformations  of  the  brain  and  spinal  cord,  their  membranous  sheaths 
and  osseous  cases,  and  of  defect  and  malformation  of  other  organs  which 
have  hitherto  been  considered  as  anomalies  of  original  development. 

Thus  we  observe  hypertrophy  of  the  brain,  which  in  rare  cases  attains 
such  an  extent  as  to  cause  the  development  of  the  cranium  to  appear 
entirely  arrested. 

Apoplexy  occurs  very  rarely  as  hemorrhage  within  the  substance  of 
the  brain ;  but  we  often  find  both  in  the  foetus  and  the  new-born  infant  a 
vascular  apoplexy,  and  extravasation  into  the  tissue  of  the  membranes 
and  into  the  cavity  of  the  arachnoid. 

Inflammation  and  its  consequences,  inflammatory  softening  and  com- 
plete liquefaction  of  the  brain,  are  much  more  frequent.  These  and 
hydrocephalus  are  doubtless  the  commonest  cerebral  diseases  of  the  foetus, 
and  upon  the  former  the  defects  and  numerous  malformations  depend 
which  are  found  in  hydrocephalic  foetuses. 

Hydrocephalus  and  hydrorrhachis  are,  in  the  foetus  as  at  a  later  period, 
the  result  of  repeated  exudative  processes  affecting  the  investments  of 
the  cerebral  cavities  and  the  spinal  canal.  They  are  well  known  often 
to  attain  such  a  degree,  that  not  only  the  dilated  and  imperfectly  ossified 


THE    F(ETUS.  265 

cranium  offers  an  obstacle  to  parturition,  but  that  the  brain  and 
the  spinal  cord  are  gradually  destroyed  by  compression  ;  that  they  are 
ruptured  at  an  early  stage  of  embryonic  life,  or  are  dislocated  in  various 
directions,  and  forced  out  of  the  cranium  at  later  periods. 

In  the  respiratory  apparatus  of  the  foetus  we  find  that  the  pulmonary 
parenchyma  and  the  bronchi  occasionally  become  diseased.  The  former 
is  said  to  have  been  found  in  a  state  of  hepatization,  and  even  abscesses 
have  been  seen  in  the  lungs.  The  bronchi  are  frequently  charged  with 
mucus,  and  atelectasis  neonatorum  is  probably  caused  by  a  mere  ca- 
tarrhal  affection  of  the  mucous  membrane,  and  an  obstruction  of  the 
capillary  bronchi  by  mucus.  (Vid.  Vol.  III.,  Acute  Catarrh  of  Respir. 
Org.) 

The  thymus  gland  of  the  foetus  may,  according  to  Veron,  be  attacked 
by  inflammation  and  suppuration. 

In  the  digestive  apparatus,  the  peritoneum,  the  entire  intestine,  and 
its  appendages  may  become  diseased  during  uterine  existence. 

The  peritoneum  is  frequently  the  seat  of  inflammation  of  an  acute  or 
chronic  character,  causing  exudations,  that  vary  in  quantity  and  quality. 
It  may  be  limited  to  one  portion,  or  be  universal.  It  not  only  induces 
thickening  of  the  peritoneum,  but  also  adhesions  among  the  abdominal 
viscera,  and  between  them  and  the  parietes ;  the  sooner  it  sets  in,  the 
more  it  is  likely  to  operate  as  the  cause  of  numerous  anomalies  in  the 
abdomen,  which  have  been  hitherto  considered  as  cases  of  arrest  of  de- 
velopment. (Simpson.)  The  inflammation  may  originate  in  unknown 
causes,  or  in  such  as  are  anatomically  demonstrable,  as  constriction  of 
the  intestine,  hemorrhage  of  the  liver  into  the  peritoneal  cavity,  extra- 
vasation of  the  contents  of  the  intestines,  or  of  urine ;  the  latter  may 
occur  at  a  very  early  period,  for  it  has  been  noticed  in  a  foetus  of  four 
months.  It  sometimes  kills  the  foetus  before  maturity,  at  others  death 
ensues  shortly  after  birth. 

As  regards  the  alimentary  tube,  both  hyperaemia  of  its  mucous  mem- 
brane and  anaemia,  with  waxy  paleness  and  softening,  have  been  fre- 
quently observed.  The  latter  affection  is  of  particlar  importance  in  the 
foetus.  The  former  not  unfrequently  attains  such  a  degree  as  to  warrant 
the  application  of  the  term  apoplexy ;  it  is  generally  associated  with  hy- 
peraemia  of  other  abdominal  viscera  and  general  plethora,  and  may  be 
accompanied  by  ecchymoses  in  the  tissues  and  extravasation  of  blood  into 
the  intestinal  cavity. 

Inflammation  and  the  allied  processes  are  generally  limited  to  the 
follicular  apparatus  of  the  ventricular  and  intestinal  mucous  membrane, 
which  are  comparatively  very  much  developed.  The  former  occasionally 
presents  a  hemorrhagic  fusion  (erosion)  of  the  follicles  in  a  very  marked 
degree ;  the  follicular  apparatus  of  the  intestinal  mucous  membrane  is 
still  more  frequently  diseased.  In  the  small  intestine,  the  glands  of 
Peyer  are  chiefly  found  more  or  less  swollen,  reddened,  and  of  a  fleshy 
sarcomatous  appearance,  or  pale,  i.  e.  yellow  or  grayish-red,  containing 
like  the  solitary  follicles,  a  variety  of  reddish  or  grayish,  more  or  less 
dense,  opaque,  milky  or  curdled,  serous,  flocculent  fluids.  These  morbid 
enlargements  of  the  intestinal  follicles,  caused  by  tumefaction  and  im- 
bibition of  the  tissues,  and  the  presence  of  a  variously  modified  product, 

VOL.  II.  18 


266  ABNORMITIES    OF 

are  here  too  undoubtedly  (vide  p.  78)  closely  associated  with  anomalies 
in  the  vital  fluids,  with  morbid  conditions  of  the  mesenteric  glands,  ab- 
normal enlargement  of  the  thymus,  or  with  tumefaction  of  the  spleen, 
but  their  real  nature  remains  an  enigma.  The  indurated  swellings  of 
the  Peyerian  glands  occasionally  resemble  closely  the  typhoid  infiltration 
found  in  adults,  and  may  indeed  result,  if  not  from  an  identical,  at  least 
from  a  very  similar  process.  Follicular  tumefaction  also  occurs  fre- 
quently in  the  large  intestine  of  the  foetus  and  the  new-born  infant ;  and, 
as  in  the  adult,  without  any  coexistent  affection  of  the  small  intestine. 
The  follicles  appear  much  reddened,  the  entire  mucous  membrane  is 
swollen,  and  invested  with  a  yellowish-white  secretion. 

In  very  rare  cases  we  meet  with  a  diffused  croupy  inflammation,  and 
a  corresponding  product  in  the  intestinal  mucous  membrane. 

The  processes  which  we  have  just  considered,  do  not  appear  to  lead 
to  ulceration  in  the  foetus ;  still  there  are  cases  on  record  of  extensive 
ulcerative  affections  of  the  oesophagus  and  the  entire  alimentary  tract. 

Tumors  and  excrescences  have  been  observed  on  the  internal  surface 
of  the  intestine,  as  well  as  callosities  of  the  interstitial  cellular  tissue, 
especially  of  the  stomach. 

The  foetal  liver  is  very  often  the  seat  of  hypersemia,  which,  on  account 
of  the  delicacy  of  the  hepatic  tissue,  easily  degenerates  into  apoplexy 
with  rupture. 

Various  infiltrations  of  the  hepatic  parenchyma  may  form  even  during 
foeta  existence,  and  we  thus  find  the  fatty,  the  waxy,  the  lardaceous 
liver  accompanied  by  the  characteristic  enlargement,  in  which  the  left 
lobe,  which  at  that  period  is  comparatively  of  large  dimensions,  neces- 
sarily participates. 

In  the  same  manner,  the  spleen  of  the  foetus  may  suffer  ;  it  is  often 
found  in  a  state  of  acute  or  of  chronic  tumefaction,  presenting  in  the  first 
case  looseness,  in  the  second,  remarkable  condensation,  resistency,  and 
frangibility  of  texture.  Tumors  of  the  spleen  bear  the  same  import  as 
in  the  adult,  and  result  from  the  relation  existing  between  the  spleen 
and  dyscrasic  conditions  of  the  blood.  They  occasionally  attain  a  con- 
siderable size. 

The  salivary  glands,  and  especially  the  pancreas,  are  very  rarely  af- 
fected in  the  foetus  ;  the  cancerous  induration  of  the  pancreas  noticed 
at  page  140  must  be  considered  as  extremely  remarkable. 

The  urinary  organs  of  the  foetus  do  not  frequently  become  diseased, 
but  their  affections  occasionally  attain  a  very  considerable  development. 
The  kidneys  are  subject  to  hypergemia  and  apoplexy ;  the  passages  have 
been  found  excessively  dilated,  to  an  extent  varying  with  the  seat  of 
contraction  or  obturation ;  and  the  bladder  has  even  been  ruptured  from 
the  same  cause.  We  quote  the  following  case,  taken  from  a  preparation 
which  is  preserved  in  the  Viennese  Museum,  both  because  it  presents 
analogies  to  the  various  observations  of  this  character  that  have  been 
recorded,  and  on  account  of  several  peculiarities  which  it  offers  :  A  new- 
born male  infant  with  a  large  abdominal  cavity,  is  provided  with  a  blad- 
der of  the  size  of  a  child's  head,  collapsed  and  agglutinated  to  the  abdo- 
minal parietes  by  a  thick  exudation.  The  membranes  are  traversed  by 
varicose  veins,  which  presented  a  blue  color  when  fresh,  and  the  urethra 


THE    FOETUS.  267 

is  narrow,  though  patent.  The  inferior  portions  of  the  ureters  are  di- 
lated to  the  size  of  the  small  intestine  of  an  adult,  the  upper  portions  less 
so,  the  right  being  of  the  size  of  a  little  finger,  the  left  one  larger ;  the 
pelves  and  calices  of  the  kidneys,  which  are  of  the  size  of  walnuts,  are 
moderately  dilated.  The  ureters  are  coiled  up  and  bent,  and  their 
curvatures  are  bound  down  by  a  tense  cellular  sheath :  both  terminate 
blindly  at  the  sides  of  the  bladder.  The  right  one  is  accompanied  by  an 
unsymmetrical  umbilical  artery,  which  proceeds  from  the  point  of  origin 
of  the  renal  arteries.  All  the  other  abdominal  viscera  are  pushed  up- 
wards, and  the  entire  intestine  is  very  narrow,  scarcely  presenting  a 
diameter  of  one  line ;  the  abdominal  integuments  are  oedematous,  and  are 
superficially  ulcerated,  below  the  insertion  of  the  umbilical  cord,  to  an 
extent  of  three  inches  by  nine  lines  or  one  inch.  They  are  considerably 
thinned,  and  of  an  irregular  thickness,  presenting  a  cribriform  perfora- 
tion at  one  spot,  and  adhering  to  the  anterior  surface  of  the  bladder. 
The  peritoneum  was  invested  by  a  plastic  exudation,  and  contained  six 
ounces  of  a  yellow,  opaque  fluid. 

The  cysts  of  which  we  have  spoken  at  page  159,  also  occur  in  the  foetal 
kidneys,  and  may  be  so  numerous  that  the  latter  appear  converted  into 
one  mass  of  cysts. 

We  frequently  have  opportunities  of  observing  spots  in  the  foetal  kid- 
neys which  are  variously  discolored,  and  which  present  a  morbid  indu- 
ration of  the  tissue.  They  most  probably  result  from  inflammation,  and 
are  occasionally  associated  with  traces  of  a  similar  process  in  the  adipose 
sheath  of  the  kidneys. 

The  suprarenal  capsules  have  been  found  in  a  state  of  suppuration. 


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